Medical transcriptionist

Job Description:

Responsibilities

• converts physicians' and other healthcare providers' voice recordings into accurate written discharge summaries, ensuring the integrity and confidentiality of patient medical records.
• responsible for producing accurate and timely documentation of patient encounters, diagnostic test results, procedures, and consultation notes, which become a permanent part of the patient's medical record.
• Adhere strictly to confidentiality protocols, data security guidelines, and legal and ethical requirements when handling sensitive patient information.
• Assist with filing, organizing records, and other administrative tasks related to medical documentation as needed.
• maximizing discharge turnaround times (TAT), optimizing bed turnover, and ensuring strict compliance with healthcare regulatory guidelines (like HIPAA or NABH).
• creates, edits, and finalizes patient discharge records.
• Review and proofread automated drafts generated by Speech Recognition Software (SRS), correcting errors in context or dictation.
• Accurately capture final diagnoses, surgical procedures, patient histories, drug dosages, and post-discharge home care instructions.
• Translate medical jargon and shorthand into standard, fully spelled-out clinical language.
• Meet strict daily deadlines (e.g., final summaries ready within hours of a planned discharge) to facilitate smooth billing and patient exit.
• Directly upload completed documents into the HIS and Electronic Health Records (EHR)