Medical Records Transcriptionist transcribes medical dictation by physicians and other medical practitioners pertaining to patients assessment, diagnostics, therapy, and other medical reports. Understands medical terminology and the use of transcription software and equipment. Being a Medical Records Transcriptionist requires a high school diploma. May require Registered Healthcare Documentation Specialist (RHDS). Additionally, Medical Records Transcriptionist typically reports to a supervisor or manager. The Medical Records Transcriptionist works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be a Medical Records Transcriptionist typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
Essential Functions:
Prepare and assemble medical records.
· Organize and analyze medical records for accuracy and completeness.
· Identify, track and enter practitioner deficiencies in Medhost.
· Pull charts as requested for audits, peer review, readmissions, HBIPS processing and route to appropriate area or department.
· Ensure files are stored in the designated area according to storage procedures.
· Maintain and search computerized medical records.
· Maintain chart control, access and storage in accordance with established policies, procedures and regulations.
· Process medical records requests according to policy and procedure.
· Scan records to contract coders for processing, when applicable.
· Assist with HIM department audits including HBIPS, CMS Quality Measures, and concurrent reviews.
· Pick up discharge records from patient units.
· Assemble new admission folders, if applicable.
· Print and deliver medical records forms to patient units.
· Search and print dictated reports from computerized transcription system.
· Purge and inventory medical records for off-site storage.
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