Healthcare Documentation Specialist
Professional Level 1
Position Summary
Medical language specialist who transcribes dictation by physicians and other healthcare providers in order to document patient care. The incumbent will likely need assistance to interpret dictation that is unclear or inconsistent, or make use of professional reference materials.
Nature of Work
An incumbent in this position is given assignments that are matched to his or her developing skill level, with the intention of increasing the depth and/or breadth of exposure. Or, the nature of the work performed (type of report or correspondence, medical specialty, originator) is repetitive or patterned, not requiring extensive depth and/or breadth of experience.
Knowledge, Skills, and Abilities
- Basic knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values. Knowledge of specialty (or specialties) as appropriate.
- Knowledge of medical transcription guidelines and practices.
- Proven skills in English usage, grammar, punctuation, style, and editing.
- Ability to use designated professional reference materials.
- Ability to operate word processing equipment, dictation and transcription equipment, and other equipment as specified.
- Ability to work under pressure with time constraints.
- Ability to concentrate.
- Excellent listening skills.
- Excellent eye, hand, and auditory coordination.
- Ability to understand and apply relevant legal concepts (e.g., confidentiality).
Professional Level 2
Position Summary
Medical language specialist who transcribes and interprets dictation by physicians and other healthcare providers in order to document patient care. The position is also routinely involved in research of questions and in the education of others involved with patient care documentation.
Nature of Work
An incumbent in this position is given assignments that require a seasoned depth of knowledge in a medical specialty (or specialties). Or, the incumbent is regularly given assignments that vary in report or correspondence type, originator, and specialty. Incumbents at this level are able to resolve non-routine problems independently, or to assist in resolving complex or highly unusual problems.
Knowledge, Skills, and Abilities
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- Seasoned knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values. In-depth or broad knowledge of a specialty (or specialties) as appropriate.
- Knowledge of medical transcription guidelines and practices.
- Excellent skills in English usage, grammar, punctuation, and style.
- Ability to use an extensive array of professional reference materials.
- Ability to operate word processing equipment, dictation and transcription equipment, and other equipment as specified, and to troubleshoot as necessary.
- Ability to work independently with minimal or no supervision.
- Ability to work under pressure with time constraints.
- Ability to concentrate.
- Excellent listening skills.
- Excellent eye, hand, and auditory coordination.
- Proven business skills (scheduling work, purchasing, client relations, billing).
- Ability to understand and apply relevant legal concepts (e.g., confidentiality).
- Certified Medical Transcription (CMT) or Certified Healthcare Documentation Specialist (CHDS) status preferred.
Professional Level 3
Position Summary
Medical language specialist whose expert depth and breadth of professional experience enables him or her to serve as a medical language resource to originators, coworkers, other healthcare providers, and/or students on a regular basis.
Nature of Work
An incumbent in this position routinely researches and resolves complex questions related to health information or related documentation. AND/OR Is involved in the formal teaching of those entering the profession or continuing their education in the profession. AND/OR Regularly uses extensive experience to interpret dictation that others are unable to clarify. Actual transcription of dictation is performed only occasionally, as efforts are usually focused in other categories of work.
Knowledge, Skills, and Abilities
- Recognized as possessing expert knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values related to a specialty or specialties.
- In-depth knowledge of medical transcription guidelines and practices.
- Excellent skills in English usage, grammar, punctuation, and style.
- Ability to use a vast array of professional reference materials, often in innovative ways.
- Ability to educate others (one-on-one or group).
- Excellent written and oral communication skills.
- Ability to operate word processing equipment, dictation and transcription equipment, and other equipment as specified, and to troubleshoot as necessary.
- Proven business skills (scheduling work, purchasing, client relations, billing).
- Ability to understand and apply relevant legal concepts (e.g., confidentiality).
- Certified Medical Transcription (CMT) or Certified Healthcare Documentation Specialist (CHDS) status preferred.
About the Professional Levels
In an independent benchmarking study of the medical transcription profession by the Hay Management Consultants (HayGroup), three distinct professional levels for medical transcriptionists were identified and described as presented above. The HayGroup is a worldwide human resources consulting firm with extensive expertise in work analysis and job measurement.
