What Does a Healthcare Documentation Specialist Do?

Healthcare Documentation Specialist

A healthcare documentation specialist or a medical transcriptionist is a crucial resource for a healthcare facility for, the important task of documenting a patient’s visit is performed by a transcriptionist. A medical transcriptionist listens to the voice recording of a physician and transcribes it into a report in a prescribed format. A transcriptionist may even review or edit a transcribed report provided by speech recognition software since the transcribed document becomes a valid legal medical record and has a critical role in the decision-making process of the physician regarding the course of action and also becomes a record for future references.

Healthcare documentation jobs involving transcribing, proofreading, and editing medical reports are highly skilled jobs and require people with enormous patience levels, focus, and eye-for-detail. Healthcare documentation specialists need to develop an extensive knowledge of medical terminology and human anatomy to be able to understand what doctors and other healthcare professionals are speaking about and transcribe it accurately. A transcriptionist has to gain exceptional proficiency in the medical terminology because what he/she reports will become a permanent legal record for the healthcare facility and any flaws in it can affect the health of the patient concerned and result in ruining the image of the facility.

Medical transcriptionists need to ensure that the reports they send to the facility are flawless, accurate and as per the guidelines of the facility. For this purpose, they need to proofread and edit what they have transcribed. Apart from the knowledge in medical terminology and anatomy, what a healthcare documentation specialist needs is exceptional language skills including grammar to be able to prepare error-free transcription reports. Many times, there would not be enough clarity in physicians’ voice recordings that may result in different types of errors related to medical terminology, numerical usage, spellings, and grammar. Although they tend to look trivial matters, even a slight change in numerical value or spelling can alter the context of a report leading to wrong decision-making by physicians related to treatment, prescription of medicines and their dosage, etc.

People in healthcare documentation jobs need to work on different types of reports that include medical history, physical examination report, operating room report, diagnostic imaging report, consultation report, autopsy report, discharge summary, referral letter, etc. They are needed by every type of healthcare provider like physicians, physical therapists, dieticians, etc. To work on such reports and make them absolutely correct with complete information it becomes necessary for the transcriptionists to understand not just medical terminology but keep updated with the latest trends and equipment being used for different services, procedures, and tests.

Medical transcriptionists can work at the healthcare facilities or with the healthcare documentation companies that are outsourced the task of preparing the reports. They work on computers and need a headset to listen to the physician-dictated audio files. To have control of the play and pause actions of the audio recording, they also need a key command or foot pedal while keying in the words of the report or editing the report.

Healthcare documentation is a wonderful career choice for people who are interested in the healthcare industry but could not be directly involved in providing patient care. You can enjoy a lucrative and rewarding career in medical transcription if you choose the best healthcare documentation companies.

What Does a Healthcare Documentation Specialist Do?