Transcribes, proofreads and edits complex technical medical reports for a broad range of clinical specialties and departments using digital or machine dictation and word processing equipment.

Under general supervision, independently transcribes, proofreads, and edits detailed medical reports from a broad range of medical specialties utilizing word processing software, machine dictation system, and/or other voice recording equipment.  While duties may involve allied clerical functions, the major responsibility is to produce a volume of accurate medical transcription to specified department standards.

Schedules, organizes, and performs medical transcription for- professional and/or contract staff such as physicians, physician assistants, psychiatrists, psychologists, nurses, occupational therapists, and social workers; 

Produces and/or revises a wide variety of complex technical medical and clinical documents and reports from tape, diskette, and voice recordings.  For example:  psychiatric evaluations, competency evaluations, physical assessments, chemical dependency reports, progress reports, case reviews, discharge and/or release summaries, and mortality/morbidity reviews;  

Merges transcribed material with information abstracted from patient records, database files, and other sources to produce reports and summaries per staff direction and/or established guidelines; 

Transcribes affidavits, petitions, and other documents required by law for use by professional/liaison staff in Superior court; 

Ensures transcribed medical and clinical records and reports are prepared in compliance with agency, state and federal directives, standards and time requirements;  

Proofreads, reviews, and edits correspondence and medical records and/or documents for completeness, format, terminology, abbreviations, symbols, grammar, punctuation, spelling, and clarity of expression; assures conformity to departmental and facility format standards; 

Uses and maintains up-to-date medical terminology/pharmacological reference sources; 

Transcribes diverse accents, dialects, and various dictation styles into cogent reports; 

Responds to questions from physicians, residents, other staff, and outside agencies regarding departmental policy and equipment usage; 

Maintains confidentiality of all transcribed materials; 

Identifies possible risk management cases; 

Assists other transcriptionists with difficult dictation and research; 

Assists in the orientation and training of students and other transcription staff; 

Trains incumbents in positions designated as In-Training to this class; 

Performs related duties such as researching medical records, logging and tracking transcribed documents; 

Copies and distributes reports; 

Performs related duties as required.

Completion of a two-year college or vocational medical secretary program, or accredited medical transcriptionist program, or equivalent.  

OR 

High school graduation or GED (General Educational Development) equivalent and two years of typing experience, including one year of occupational-level medical transcription utilizing terminology of multiple body systems or in a multi-specialty department. 

Note: Positions in this class typically require keyboarding or typing accurately at a net speed of 50 words per minute or faster.