Will “Documentation Specialist” be Automated?

Core Skills & Abilities

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

• 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.

• Take dictation using shorthand, a stenotype machine, or headsets and transcribing machines.

• Set up and maintain medical files and databases, including records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.

• Receive and screen telephone calls and visitors.

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

• Return dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.

• Receive patients, schedule appointments, and maintain patient records.

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

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

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

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

• Perform a variety of clerical and office tasks, such as handling incoming and outgoing mail, completing and submitting insurance claims, typing, filing, or operating office machines.

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