GENERAL DESCRIPTION OF CLASS

The MEDICAL TRANSCRIPTIONIST transcribes clinic reports, patient histories, physicals, progress notes, medical and dental reports, radiology reports, prescriptions, test results, medical correspondence, and other medical information from voice dictation in order to provide a permanent record of patient care. This information is dictated by medical practitioners such as physicians, physician's assistants, nurses, nurse practitioners, physical therapists, nutritionists, and other health care providers and consulting specialists working in a university student health services facility, or, in some cases, in a specialized medical facility such as Veterinary Medicine.

DISTINGUISHING FEATURES

This is a single classification and not currently part of a series of classes.

DUTIES AND RESPONSIBILITIES

1. Medical Transcription. Typical tasks: listens to and determines type of information on tape; selects appropriate format for dictated information; types clinic reports and other information from voice dictation by medical staff, covering a full range of medical treatment; uses computerized word processing and support software to produce dictated information in final form as a permanent medical and legal document for patient's medical record; reformats and codes data to populate various parts of the electronic record; proofreads, corrects and edits grammar, punctuation, and syntax; determines correct medical terminology whenever possible when dictation is muffled, or unclear, or when abbreviated and/or incorrect terms are used; retrieves information stored on disks for completion or correction of information following receipt of information from dictation author. May utilize electronic medical record format systems.
2. Information Gathering. Typical tasks: requests patient's medical record to verify or correct terminology used or procedures described in dictated information when it is unclear; may telephone dictation author to determine content or intent of unclear voice dictated information; may refer problems or questions on dictated information to clerical support staff to obtain information.
3. Record keeping. Typical tasks: maintains daily log of transcription time and line counts for each item dictated; completes weekly and/or monthly production reports; may critique work of other transcriptionists as part of quality control program.
4. Miscellaneous. Typical tasks: attends training seminars to learn about and understand changing medical technology, new diseases, treatments, and drugs. Sets up and trouble shoots dictation equipment. May perform general clerical duties as needed.

Employees in this class work independently and regularly make judgments on the correct use of medical terminology contained in the information dictated.

RELATIONSHIPS WITH OTHERS

In person or telephone contact with people outside the work unit may be limited because incoming work is dictated and received on tape. Some employees in this class may have weekly in person or telephone contact with dictation authors or clerical support staff to obtain missing information, and/or to verify or correct information dictated on tape.

SUPERVISION RECEIVED

Employees in this class receive general supervision from a program director or an administrative supervisor. Work is received by telephone dictation and/or cassette tape dictation, and the transcribed information is reviewed periodically for accuracy, completeness, appropriate formatting, minimum keystroke speed, and turnaround time of workload. The dictation author may also review the transcribed work for accuracy, completeness, and appropriate format.

State and Federal confidentiality laws, Administrative Rules, and university procedures provide guidelines for the release and processing of information. Medical dictionaries, English dictionaries, medical textbooks, reference books, and training seminars are used as references to check spelling, verify information and to keep up with information and terminology on constantly changing technology, diseases, treatment procedures, and drugs.

MINIMUM QUALIFICATIONS

One year of medical transcription experience which included:

• Using medical terminology to transcribe dictation about a full range of medical treatment and research specialties
• Operating automated word processing equipment
• Determining appropriate format for final documents
• Maintaining confidentiality of patient records
• Learning and understanding constantly changing medical terminology, new diseases, treatments, drugs, and experimental procedures