Transcribes medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. Transcribes dictated reports and translate abbreviations into fully understandable form. Edits as necessary and returns reports in either printed or electronic form for review and signature, or correction.
This career is part of the Health Science cluster Health Informatics pathway.
A person in this career:
- Takes dictation using shorthand, a stenotype machine, or headsets and transcribing machines.
- Returns dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.
- Reviews and edits transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
- Transcribes dictation for a variety of medical reports, such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, or discharge summaries.
- Distinguishes between homonyms and recognizes inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
- Translates medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.
- Produces medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
- Identifies mistakes in reports and checks with doctors to obtain the correct information.
- Performs data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
- Sets up and maintains medical files and databases, including records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.
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