Medical Transcriptionist

 Medical Transcription

• Transcribe medical reports, clinical notes, discharge summaries, operative notes, consultation notes, progress notes, and other medical documentation.
• Accurately interpret medical terminology, abbreviations, drug names, investigations, diagnoses, and procedures.
• Ensure correct spelling, grammar, punctuation, formatting, and medical terminology.
• Cross-check dictated information against available patient records wherever required.
• Clarify unclear or incomplete dictation with the concerned doctor/clinical team.
• Ensure all reports are completed within defined turnaround time (TAT).

B. Discharge Summary & Clinical Documentation

• Prepare and format discharge summaries as per hospital standards.
• Ensure discharge summaries contain relevant clinical information, diagnosis, treatment, procedures, investigations, medications, and follow-up instructions.
• Coordinate with doctors/RMOs/clinical teams for pending or incomplete documentation.
• Monitor pending reports and follow up to ensure timely completion.

C. Quality & Accuracy

• Maintain a high level of transcription accuracy.
• Review documents before final submission/upload.
• Identify discrepancies, missing information, or unclear medical terminology and escalate appropriately.
• Maintain consistency in medical terminology and hospital-approved formats.
• Participate in quality audits and corrective actions related to medical documentation.

D. Coordination

• Coordinate with consultants, RMOs, SMOs, nursing teams, medical administration, and other relevant departments.
• Follow up with doctors for pending signatures, approvals, corrections, or incomplete documentation.
• Coordinate with the Medical Records/Health Information Management team wherever required.
• Escalate critical delays or repeated pending documentation to the reporting manager.

E. Hospital Information System / Documentation

• Enter and update information accurately in the Hospital Information System (HIS/EMR).
• Upload/attach reports and documents to the appropriate patient record.
• Ensure correct patient identification before entering or uploading documentation.
• Maintain proper documentation flow and avoid duplication or incorrect uploading.

F. Confidentiality & Compliance

• Maintain strict confidentiality of patient information and medical records.
• Follow hospital policies regarding patient privacy, information security, and medical documentation.
• Do not disclose patient information to unauthorized persons.
• Handle medical records and clinical information responsibly.

G. Shift & Workflow Management

• Work according to the assigned shift/roster.
• Ensure proper handover of pending work to the next shift.
• Prioritize urgent documentation such as critical care, emergency, surgery, and discharge-related reports.
• Maintain daily productivity and TAT as defined by the department.
• Support night-shift documentation requirements as per hospital workflow.