About This Career

Transcribes medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. Transcribes dictated reports and translates abbreviations into fully understandable form. Edits as necessary and returns reports in either printed or electronic form for review and signature, or correction.

This career is part of the Health Science cluster Health Informatics pathway.

A person in this career:

• Returns dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.
• Produces medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
• Identifies mistakes in reports and checks with doctors to obtain the correct information.
• Reviews and edits transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
• Transcribes dictation for a variety of medical reports, such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, or discharge summaries.
• Sets up and maintains 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.
• Distinguishes between homonyms and recognizes inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
• Translates medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.
• Performs data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
• Takes dictation using shorthand, a stenotype machine, or headsets and transcribing machines.

Working Conditions and Physical Demands

People who do this job report that:

• You would sit most of the time. There's some walking and standing. You may have to lift and carry things like books, papers or tools weighing 10 lbs. or less.
• Work in this occupation involves using your hands to hold, control, and feel objects more than one-third of the time
• Work in this occupation requires being inside most of the time
• Work in this occupation involves sitting more than one-third of the time

Working in this career involves (physical activities):

• Seeing clearly up close
• Speaking clearly enough to be able to be understood by others
• Identifying and understanding the speech of another person

Work Hours and Travel

• Regular working hours and limited travel