Responsible for listening to and dictating records made by physicians or other healthcare professionals. Pauses recording to key in text. Edits and proofreads text for accuracy. Returns documents to physician or files away for future use.
- Transcribe dictated recordings made by physicians and healthcare professionals.
- Listen to medical reports carefully using headset.
- Pause recording using foot pedal.
- Rewind or fast forward tape for clarity.
- Write and produce discharge summaries, medical history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic-imaging studies, progress notes, and referral letters.
- Proofread document for errors and grammar.
- Return transcribed documents to point of origin, such as physician or other healthcare professional.
- File document in patient's file.
- Use medical terminology to accurately convey diagnosis or treatment.
- Translate medical jargon and abbreviations.
- Refer to standard medical reference materials for clarity.
- Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for keeping patient information confidential.
- Isolate mistakes or inconsistencies in a medical report and correct the information.
- Ensure high-quality patient care.
- Refer to Internet or digital or analog dictating equipment for dictation.
- Work with programmers and information systems staff to stream in voice communication that provides seamless data transfers through network interfaces.
- Utilize speech recognition technology.