Transcriptionist

Description

Job Title: Transcriptionist

Reports To: Histology Supervisor

Supervisor Supervises: N/A

Department: Histology

Status: Non-exempt

Job Summary

Accurately and efficiently translates Pathologist’s dictations of patient histories, diagnoses, and medical treatments, analyses of test results, medications, and prognoses into accurate and comprehensive pathology reports.

Essential Key Responsibilities

• May take dictation using either shorthand or a stenotype machine or using headsets and transcribing machines; transcribes dictated materials and/or voice recordings into an electronic comprehensive pathology report for the Pathologist in a timely manner with a high degree of accuracy using word processing and dictation equipment.
• Translates medical jargon and abbreviations into their expanded forms to ensure the accuracy of the pathology report.
• Returns dictated pathology reports in printed or electronic form to the Pathologist for review, signature, and corrections.
• Reviews and edits transcribed pathology reports for spelling, grammar, clarity, consistency, and proper medical terminology.
• Distinguishes between homonyms and recognize inconsistencies and mistakes in medical terms, referring to medical dictionaries, medical references, and other sources on anatomy, physiology, and medical terminology.
• Retrieves and produces pathology reports, correspondence, and administrative and reference material from information system, library, internet sources, medical dictionaries and medical references.
• Performs data entry and data retrieval services, providing data for inclusion in pathology reports and for transmission to Pathologists.
• Prepares pathology reports promptly and maintains an accurate medical database for patient records.
• Performs a variety of clerical and administrative functions, such as handling incoming and outgoing mail and telephone calls, drafting correspondence, maintaining calendars, scheduling appointments, arranging conference calls, meetings and travel arrangements, preparing and submitting expense reimbursements, renewing subscriptions and memberships, and organizing and maintaining paper and electronic files.
• Ensure the path report and all patient information it is correct in the system before sending it to our client.
• Maintains strictest confidentiality.
• Complies with all State, Federal, professional regulations as well as company and departmental rules, polices, and procedural manuals.
• Adherence to CLIA, State Regulations, HIPAA, Safety and OSHA
• Regulations.Performs other duties as assigned.
  
  

Education/Licensure/Certification

• High School Diploma or equivalent.
  
  

Experience

• Minimum of two years of medical transcription experience.
  
  

Equipment

• Computers, computer programs, information system(s), photocopiers, scanners, facsimile machines, dictation machines, postal machines, and telephones.
  
  

Knowledge/Skills/Abilities

• Knowledge of medical terminology including anatomy and physiology.
• Knowledge of word processing software.
• Knowledge of medical transcription guidelines and practices.
• Knowledge of English grammar, spelling, and punctuation. Page 3 of 3
• Skill in using computer programs and applications.
• Ability to listen, read, understand, and follow oral, and written instruction.
• Ability to concentrate and pay close attention to detail for extensive periods of time.
• Ability to type 80 WPM from tape using transcription equipment.
• Ability to use designated reference materials.
• Ability to establish and maintain positive relationships with employees, physicians, vendors, clients, and external agencies.
  
  

Physical Requirements

• Physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. The employee is occasionally required to stand; walk; sit; use hands to finger; handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, and the ability to focus. Requires visual acuity and normal color perception.
  
  

HIPAA/PHI Security Level: HIGH (Low, Medium, or High)

Indicate the security access level of Protected Health Information (PHI) as necessary to perform essential key responsibilities of the position (access, utilize, disclose, store, and/ or dispose of PHI).

• Low –information access is of general nature representing summary type data rather than specific identifiable demographic or sensitive data.
• Medium – information access is specific to an individual’s demographics and service information (type of service, services received, dates of service, and provider of service).
• High – information access is detailed and sensitive to an individual’s demographics, service information, and personal medical history (past/present medical conditions, specifics of medical diagnosis or tests, treatment plans, and family history).
  
  

All job requirements listed indicate the minimum level of education, knowledge, skills and/or experience necessary to proficiently perform the job. This job description is not to be construed as an exhaustive statement of duties, responsibilities or requirements. Employees will be required to perform any other job-related duties assigned by their supervisor, subject to reasonable accommodations.