Medical Transcriptionist

Job Summary

Position requires skills necessary to interpret, edit, and transcribe all reports, as well as the ability to verbally communicate with other departments, physicians and staff. This includes knowledge of medical terminology pertaining to pathology, general medicine, anatomy, and pharmacology. Must be proficient in office functions and guidelines to ensure accurate transcription of all reports. This would include autopsies, surgical reports, letters, notes, etc. General knowledge and proficiency of the hospital HIS and LIS computer systems, as well as the DVI dictation system. Handling requests to include, sending out cases, pulling cases, contacting other providers, and pulling case history if necessary. Handling department mail and reports. Check billing, follow up on mistakes from other areas of the department. Scan all patient requisitions and information into hospital system. Must be able to perform all the functions of the Administrative Assistant which includes managing the phone, faxing, directing calls and troubleshooting. Handle information for send-outs which includes maintaining the logs and packaging. Person must be self-motivated with little or no supervision needed.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent.
Minimum Years of Experience: 3 Years of experience in Medical Transcription
Substitutable Education & Experience:  3 Years of experience can be substituted for completion of an accredited Medical Secretary/Transcription Program (normally 2-24 months in duration)
Required Certifications/Licensure:  None
Required Training: Proficiency in use of dictating equipment and all Microsoft office products;
Typing Speeds 60+ Words/Minute.

Essential Functions

• Transcribes dictation from digital voice dictation system into typewritten records.
• Applies knowledge of medical terminology, anatomy and English language rules to the transcription and proofreading.
• Uses reference materials appropriately and efficiently.
• Must be sufficiently knowledgeable and familiar with language and terminology to recognize inconsistencies and discrepancies in dictation and appropriately edit, revise and clarify dictation without altering the meaning.
• Must recognize the need to seek assistance and/or bring the question to the attention of the dictating pathologist.
• Must consistently increase medical vocabulary and job knowledge specific for Pathology.
• Must possess skills for interpretation of physicians/staff’s handwriting on all documents from OR/physician’s offices, etc. in order to transcribe accurate records.
• Knows the importance of verifying patient information for accuracy.
• Always formats reports according to established guidelines and assures all reports are complete (no blanks in report) before leaving the department.
• Is proficient with Microsoft Office programs to create documents and spreadsheets as needed.
• Copies and distributes reports (Surgical Pathology, autopsy, cytology, outside consults, and related material.
• Gives Surgical Pathology report results to doctors’ offices by telephone, FAX or mail in accordance with Release of Information policy.
• Checks for incomplete and/or delayed Surgical Pathology reports frequently, pulls slides for incomplete/overdue reports and gives to the appropriate pathologist for completion, sign-out and distribution.
• Enters information for regular, required QC and QA workload reporting.

Duties & Responsibilities

• Pulls slides and/or blocks as requested by pathologists and outside offices.
• Receives and maintains records of material, reports and requests sent to and returned from outside consultants and institutions.
• Processes mail, multiple prints of current pathology reports during the day.  Some reports are faxed directly from the computer; others are prepared for mailing to appropriate offices and departments.
• Prepares in-patient reports for charting.
• Prepares material for consultations with outside pathologists and institutions to be picked up by Federal Express, couriers, etc.
• Is responsible for maintaining Quality Assurance and Quality Control records and statistics.
• Must be self-motivated and must work with little or no supervision.
• Sets priorities regarding daily workload and schedules time to accommodate work demands.
• Handles phone calls from nursing staff, in-house medical staff, off site medical and office staff, other facilities around the country.  Also demonstrates appropriate telephone communication of information with a variety of callers; i.e. patients, patient family members, insurance company personnel, coroner’s office, funeral homes, and all other business conducted by phone.
• Works with Tumor Registrar to provide records for Tumor Registry and Tumor Conference.
• Maintains an optimistic and professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers.  Shows courtesy, compassion and respect.  Conforms to Service Excellence Policy and “house rules”.
• Active participation in the LMC Service Excellence Program with on-going demonstration of active commitment to the concept of service excellence relative to patient care, employee, Medical staff and general public.
• Provides quick and easy access to printed copies of reports, letters, and FAX material, etc., by keeping files in order and up to date.
• Ensure Hazardous Waste or Hazardous Waste Pharmaceuticals are discarded, stored, and managed with other compatible waste streams in containers that are properly labeled and closed prior to being shipped offsite for proper disposal.  Initial RCRA training is received within 6 months of the hire date and continuing with annual RCRA training.
• Performs all other duties as may be assigned by authorized personnel or as required in an emergency. e.g., fire or disaster.