The Transcriptionist Medical Records interprets and transcribes medical information from tape, written text or dictation by Physician and other Healthcare professional regarding patient assessment, workup, therapeutic procedures, clinical course, diagnostic, prognosis, etc.
in order to document patient care. Performs a variety of technical duties, for proper maintenance of medical records, in addition to transcription responsibilities as per established policies & standards.
DUTIES & RESPONSIBILITIES E.R & Inpatient
Transcribes dictation / notes and types reports, patient histories, surgical procedure notes, discharge summaries, patient abstract, significant diagnostic findings, etc.
Operates designated word processing, dictation and transcription equipment as directed to complete assignments.
Verifies accuracy of patient information such as name and identification number; verifies accuracy of transcription for correct punctuation, grammar, and spelling.
Liaises with Doctors, Nurses, and other units / staff of the Hospital for timely completion of required functions.
Receives the Sick Leave / Medical Reports from the Clinic and In-Patients and transcribes all reports in a timely manner.
Engages in preparation of certificates such as To Whom It May Concern’, companion certificate etc.
Ensures that details within the reports match with the patient file.
Coordinates directly with Doctors, Nurses, PROs and receptionists for timely completion of the reports.
Follows up for appropriate signatures from the Consulting Physician, Medical Director, and attested by the Ministry of Health
Understands and complies with policies & procedures related to Medico-Legal matters including confidentiality, amendments of medical records, release of information, patient rights, medical records as legal evidence, informed consent etc.
Maintains confidentiality of patient information and prevents disclosure to unauthorized persons.
Distributes and collects dictation and transcribed reports; follows up on Physicians' missing and / or late dictations.
Provides routine information & inquiry services, collects and compiles relevant statistics.
Maintains appropriate logbook to support productivity and accountability.
Composes and types routine medical correspondence as required.
Maintains established departmental policies & procedures, objectives, quality assurance, safety and infection control standards.
Attends departmental committee meetings as required and is an active member of the Multi-Disciplinary Team.
Performs other related assignments as requested by the Manager- Medical Records.
INTERNAL : 1. Physicians and Nursing staff
2. Quality Department
3. PRO / Reception StaffEXTERNAL : 1. Patients
2. Patient Relatives & Friends
3. MOH Representatives JOB REQUIREMENTS
Education : Degree in Medical Secretarial Education or related field. Experience : 1 year relevant experience in medical records transcription in Ministry of Health. Other Skills Technical :
Knowledge of medical transcription guidelines & practices, Medical Terminologies, and Medico-Legal implications & responsibilities related to the transcription of patient records;
Ability to operate designated word processing, dictation, and transcription equipment.
Administrative Skills :
Attention to detail, Knack for different languages and accents, Ability to Focus, Prioritize and Multi-task.
Soft Skills :
Good Communication and Inter-Personal skills.
Computer Skills : MS Office (Word, Excel, Outlook), Hospital MIS, and Typing speed of at least 40 wpm with 90% accuracy.
Language Skills : Good in written and spoken English, Arabic. WORKING CONDITIONS Works indoors throughout the shift in temperature controlled, clean, well lit and pleasant surroundings.
Considerable sedentary work with prolonged or substantial sitting / standing for long hours. May experience eye-strain and neck & back fatigue due to nature of the job Split duty, straight and other combination of duty situation may be necessary.