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)
Responsible and accountable for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
§ Prepares charts for new admissions.
§ Closes medical records upon discharge.
· Develops schedule for and conducts audits of the clinical and electronic health records.
· Monitors physician visit schedule.
· Maintains master index system.
· Orders, maintains, and distributes medical records forms.
· Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.
· Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.
ENTRY QUALIFICATIONS
· High school diploma or equivalent.
· Working knowledge of medical terminology.
· Proficient in the use of personal computer.
SUPERVISORY RESPONSIBILITIES
Supervises Medical Record assistant, if any, and others for whom they are administratively or professionally responsible.
Clear All
0 Medical Records Transcriptionist jobs found in Santa Cruz, CA area