Description

Classification: Non-Exempt 

Position Type: Full-time 

Reports to:  Director/Supervisor 

Department: Medical Records

Summary/Objective:

Under the direction of the Director/Supervisor, transcribes technical medical data from recorded dictation; audits, sorts and files copies of transcribed reports, distributes copies of transcribed reports to the physicians and reviews medical records for completeness and accuracy. Responsible for preserving the privileged contents of the records and other information of a confidential nature obtained in an official capacity. Also responsible for Release of information duties that include: retrieving medical records on demand, maintaining patient records, organizing files, searching for patient files, reporting to medical staff, and solving inconsistencies.

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Transcribes and types medical reports such as discharge summaries, operative reports, history and physicals, progress notes, consultation reports and similar medical reports from recorded dictation. 

2. Ensures correct spelling of medical terms and other words, correct punctuation and grammar in the transcribed reports, and makes necessary corrections without changing the sentence meaning.

3. Sorts originals and copies of reports for distribution.

4. Photocopies transcribed reports and distributes copies to physicians when necessary

5. Processes requests for information according to procedure, analyzing the request for appropriate consent for release, computing appropriate fee for copies, bills for records and mails records in the time frame required by law. Protects the privileged contents of the medical records and other confidential information obtained in performing these tasks, duties and responsibilities by adhering strictly to the release of information policies of the hospital.

6. Performs audits of medical records for monitoring timely completion, content sufficiency and appropriate documentation.

7. May perform other duties not directly addressed in this job description, but which he/she has been adequately trained.

8. Answers telephone, takes messages and communicates messages to the appropriate person.

Requirements

Competencies:

Accurately transcribe medical reports at an acceptable rate

Working knowledge of medical terminology, human anatomy and pathophysiology

Communication proficiency

Ethical Conduct

Flexibility

Supervisory Responsibility:

This position has no supervisory responsibilities

Work Environment:

This job will require exposure to co-workers and the public. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, fax machines, and other equipment as needed. 

Physical Demands:

The physical demands described as follows are representative of those that must be met by an employee to successfully perform the essential functions of this job. 

While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include near sight acuity. This position requires the ability to sit, stand and move around. Duties regularly require standing, walking, bending, pushing, pulling, as well as lifting and/or moving up to 10 lbs.

Position Type/Expected Hours of Work

This is a full time position, and core hours of work are Monday through Friday 8 hours per day. Position may require work schedule flexibility based on needs of the facility.

Travel

Occasional travel is expected for this position due to training needs.

Required Education, Experience and License

High school diploma or equivalent

One year of experience in a medical records department and/successful completion of a program for registered health information technician.

Preferred Education, Experience and License

Registered health information technician (HIT) preferred