Job Description:

To accurately transcribe, format, review, and maintain clinical documentation dictated or recorded by physicians and other authorized healthcare professionals, ensuring accuracy, confidentiality, timely availability, and compliance with hospital documentation standards.

Key Responsibilities

1. Medical Transcription

- Transcribe clinical dictations, including consultation notes, discharge summaries, operative notes, procedure notes, progress notes, and other medical reports.
- Accurately capture medical terminology, diagnoses, medications, investigations, procedures, and clinical findings.
- Ensure appropriate formatting and standardization of clinical documents.

2. Quality & Accuracy
- Proofread transcribed documents for spelling, grammar, punctuation, formatting, and medical terminology.
- Cross-check patient identifiers and relevant clinical information to minimize documentation errors.
- Clarify unclear or ambiguous dictations through the appropriate physician/channel rather than making assumptions.
- Maintain high standards of accuracy and turnaround time.

3. Electronic Medical Records (EMR)
- Enter and/or upload completed documents into the hospital's designated EMR/HIS.
- Ensure reports are correctly linked to the appropriate patient record.
- Follow hospital protocols for electronic authentication, amendments, and document version control.

4.



Confidentiality & Data Security
- Maintain strict confidentiality of patient information in accordance with hospital policy and applicable privacy requirements.
- Access patient records only when authorized and required for assigned duties.
- Ensure that printed, electronic, and dictated clinical information is appropriately secured.

5. Coordination
- Coordinate with consultants, clinicians, medical records, nursing, and other departments for completion of pending documentation.
- Follow up on delayed or incomplete reports as per defined turnaround times.
- Escalate recurring documentation issues to the reporting manager.

6. Compliance & Documentation Standards
- Follow hospital policies, SOPs, medical documentation standards, and applicable accreditation requirements.
- Support medical records audits and quality-improvement initiatives.
- Maintain appropriate records of completed, pending, and corrected transcriptions.

Key Performance Indicators (KPIs)
- Transcription accuracy
- Turnaround time (TAT)
- Percentage of reports completed within defined TAT
- Number of documentation errors/rework
- Compliance with patient identification requirements
- EMR documentation accuracy
- Confidentiality and information-security compliance
- Physician/department satisfaction

📌 MT-Medical Administration (Noida)
🏢 Max Healthcare
📍 Noida