Medical Scribe-Health Information Management

Accompany physicians during patient visits to document real-time interactions and medical information directly into electronic health records Prepare and assemble medical record documentation and charts for the physician before and after patient encounters. Accurately transcribe patient histories, physical examinations, procedures, lab results, and physician observations as dictated during the visit. Ensuring transcription of all medical reports e.g. Discharge summaries, operative reports, cardiology reports, electroencephalogram (EEG) reports, pathology reports, medical evaluations, history and physical reports, consultation notes and progress notes and other medico legal documents as necessary in an accurate and timely manner to document patient care. Applying knowledge of medical terminology, pharmacology, anatomy and physiology, disease processes, signs and symptoms, laboratory values related to a specialty or specialties and English language rules to the transcription and proofreading of medical dictation from originators with various accents, dialects and dictation styles utilizing in-depth knowledge of medical transcription guidelines and practices. Translating of dictated medical slang and abbreviations into their expanded form to ensure the accuracy of the patient and health care facility records. Clarifying dictated information that is unclear or incomplete, utilizing the electronic medical record to confirm laboratory and radiology results, diagnoses and medication/dosages and seeking assistance from physicians, nursing units, offices and/or ancillary departments as necessary. Submitting all transcribed reports to the physician responsible for review, signature, JOB DESCRIPTION correction, approval and insertion into the patient medical record. Operating word processing equipment, dictation and transcription equipment and other equipment as specified and troubleshooting as necessary. Ensuring accuracy of the header and footer, and the correctness of the body of the transcribed material Ensuring that transcribed document is consistent with all recognized standards Recording productivity and ensuring quality monitoring daily. Keeping accurate work logs and editing sheets and ensuring the electronic record of dictations is kept accurate. Responding to verbal and written inquiries in a timely manner Providing technical expertise in identifying potential issues Participating in all team efforts as required Collaborating with other members of the team to carry out work smoothly Accountabilities Ensure completeness, accuracy, and timeliness of all medical documentation and patient records Maintain compliance with hospital, clinic, and legal regulations, including HIPAA, DOH, and other accreditation standards. Support efficient clinic workflow and provider productivity by reducing the administrative burden on clinicians. Ensure all documentation is reviewed and authenticated by the physician. Maintain a high standard of professionalism, discretion, and patient privacy at all times. Education, Certifications, and Professional Experience (Required for satisfactory performance on the job) Required: Bachelor s in health information management or relevant field or Diploma with 3 years of additional experience Desired: Bachelor s degree in a related field Specialist Certifications: Required: N. A. Desired: Certification as a Certified Medical Transcriptionist, or equivalent Experience: Required: UAE Nationals ONLY 2 4 years of medical transcription experience in an acute care hospital setting or comparable setting. Desired: Experience in a large healthcare facility Proficiency in EHR systems and medical recording software. Strong knowledge of medical terminology, diagnoses, and procedures. Fast and accurate typing skills (typically 60 80 words per minute). Excellent written and verbal communication skills. Strong organizational, multitasking, and time management abilities. Ability to work in high-pressure, fast-paced clinical environments. Good interpersonal skills for working alongside providers and interacting with patients. High attention to detail and accuracy in documentation. Adaptability to different providers, specialties, and clinical settings.