Medical Scribe-Health Information Management

Sheikh Shakhbout Medical City · Abu Dhabi

• 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 correct spelling of medical terms, correct punctuation, and grammar
Ensuring proper identification of patient name and medical record number
Identifying, interpreting and evaluating inconsistencies, discrepancies and inaccuracies in

medical dictation; appropriately editing, revising and clarifying them without altering the
meaning of the dictation or changing the originator's style.
• Recognizing and reporting unusual circumstances and/or information with possible risk
factors to line manager.
• Recognizing and reporting problems, errors and discrepancies in dictation and patient records
to appropriate channels.
• Verifying patient information for accuracy and completeness utilizing the electronic medical
record.

Identifying and eliminating duplicate records both paper and electronic in the dictation system
Staying current with clinical terminologies through publications, seminars, continuing

education programs and other changes in the medical industry

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.

At SSMC, we firmly believe that the human touch is a fundamental part of care. We understand that health care is both an art and a science, running deeper than simply diagnosing and treating those who rely on us. Our SSMC Model of Care puts our patients at the forefront of our purpose and at the heart of everything we do, ensuring that the needs of our patients come first. Every one of our patients receives individualized attention from a multidisciplinary team of experts who collaborate closely to deliver trusted and compassionate care. From the very first point of contact with SSMC, to the moment patients are back home, we ensure speciality-specific care at every stage and in every interaction. As one of the largest tertiary hospitals in the UAE, SSMC provides access to specialist medical treatments and advanced diagnostics, with a commitment to becoming a Destination Medical Center in the UAE and wider region.

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