Qualifications/Responsibilities:

· Decide which information should be included or excluded in reports.

· Distinguish between homonyms, and recognize inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.

· Identify mistakes in reports, and check with doctors to obtain the correct information.

· Perform data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.

· Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.

· Return dictated reports in printed or electronic form for physicians’ review, signature, and corrections, and for inclusion in patients’ medical records.

· Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.

· Take dictation using either shorthand or a stenotype machine, or using headsets and transcribing machines; then convert dictated materials or rough notes to written form.

· Transcribe dictation for a variety of medical reports such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, and/or discharge summaries.

· Translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.

· Answer inquiries concerning the progress of medical cases, within the limits of confidentiality laws.