Career Map: Healthcare Documentation Roles
Healthcare Documentation Specialist 1
Summary:
Healthcare Documentation Specialist, Level 1, transcribes and/or edits basic patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 1 individuals possess basic or entry-level knowledge with little to no transcription or editing experience. Nature of work performed would start at entry level and increase as depth and breadth of knowledge, exposure to specialties, and dictators and/or types of documentation can be produced while meeting departmental quality and production expectations.
Educational Background:
- High school diploma or GED required
- Vocational/technical healthcare documentation/transcription training required
Experience Required:
- None or minimal medical transcription experience; some organizations may require 1 year of practical experience
Healthcare Documentation Specialist 2
Summary:
Healthcare Documentation Specialist, Level 2, transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 2 individuals possess proficient knowledge within certain areas of expertise and can meet departmental expectations. Nature of work performed is for a specific medical specialty or at a community hospital level with limited dictators and/or types of documentation produced. AHDI certification is preferred (RHDS, CMT, or CHDS).
Educational Background:
- High school diploma or GED required
- Vocational/technical healthcare documentation/transcription training required
- Demonstrates continued educational credits in the medical field preferred
Experience Required:
- More than 1 year healthcare documentation experience within a setting with limited scope such as a community hospital, emergency, ambulatory or certain medical specialty (radiology, cardiology, neonatal, a specific clinic, etc.)
Healthcare Documentation Specialist 3
Summary:
Healthcare Documentation Specialist, Level 3, transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 3 individuals possess proficient knowledge in the field of healthcare documentation. Nature of work performed crosses all medical specialties in a large acute care setting. Individuals may perform QA tasks, mentor peers, and/or assist with projects. AHDI certification is preferred (RHDS, CMT, or CHDS).
Educational Background:
- High school diploma or GED required
- Vocational/technical healthcare documentation/transcription training required
- Demonstrates continued educational credits in the medical field required
Experience Required:
- More than 3 years’ healthcare documentation experience at a large acute care facility, with knowledge and expertise ranging across multiple medical disciplines and specialties
Medical Scribe
Summary:
The medical scribe plays an integral role in allowing healthcare providers to focus directly on patients in the clinical setting. By assuming responsibility of the interaction between patient and provider for documentation within the electronic health record, the scribe contributes to overall efficiency and patient satisfaction. Scribes are discreetly and unobtrusively present for the encounter but do not touch the patient or engage in any type of patient care. All scribe-created documentation is reviewed and/or edited by the provider, who is the one ultimately responsible for its content. An attestation is added to all documents to ensure that the scribed chart accurately reflects all work performed by the provider. Scribes may perform other clerical duties as needed. Training and ongoing support to be provided.
Educational Background:
- College graduate, student enrolled, or interested in pursuing a healthcare professional career; exceptions made for individuals with equivalent experience
Experience Required:
- Working knowledge of medical terminology
- Medical background (healthcare documentation specialist, medical assistant, medical student) preferred
- Excellent verbal and written communication skills
- Typing speed minimum of 65 WPM
Veterinary Scribe
Summary:
The veterinary scribe plays an integral role in allowing veterinarians and credentialed veterinary technicians to focus directly on patients throughout the care process. Veterinary scribes assume responsibility for documenting the details of a clinical encounter within the electronic medical record while the veterinary care team gathers patient history, conducts physical examination, and creates a treatment plan. Scribes may be discreetly and unobtrusively present for the encounter but do not touch the patient or engage in any type of patient care. All scribe-created documentation is reviewed and/or edited by the provider, who is the one ultimately responsible for its content. An attestation is added to all documents to ensure that the scribed chart accurately reflects all work performed by the provider. The veterinary scribe helps to streamline the workflow process and helps to ensure client satisfaction. Scribes may perform other clerical duties as needed such as creating estimates, inputting charges, keeping provider informed of any new test results, etc.
Educational Background:
- College graduate, student enrolled, or interested in pursuing a veterinary technician career; exceptions made for individuals with equivalent experience
Experience Required:
- Working knowledge of medical terminology, laboratory, pharmacology, and imaging terminology
- Veterinary healthcare documentation and electronic medical records
- Excellent verbal and written communication skills
- Working knowledge of law and the medical record
- CVHDP credential (preferred)
Senior Medical Scribe
Summary:
In addition to the regular duties of a medical scribe, the senior medical scribe acts as an onsite supervisor and liaison. The senior medical scribe provides administrative support and quality assurance while ensuring proper staffing levels/shift coverage/training support. The senior medical scribe mentors up to 30 scribes. They serve as a local point contact with the facility, ensuring effective two-way communication between the scribes and the facility. May require some travel between facilities.
Educational Background:
- College graduate, student enrolled, or interested in pursuing a healthcare professional career; exceptions made for individuals with equivalent experience.
- Healthcare-related credential preferred
Experience Required:
- Successful completion of a Medical Scribe program
- Experience in delivering client-focused solutions based on customer needs preferred
- Leadership experience preferred
- Teaching/mentoring experience preferred
- Strong computer skills required
Healthcare Documentation Specialist Supervisor
Summary:
Supervises and oversees the daily activities of the HIM Healthcare Documentation department and its practitioners to ensure the timely delivery of quality services. Coordinates and monitors day-to-day transcription operations. Oversees training of staff and provision of resources to staff. Is knowledgeable about all equipment and applications used and can troubleshoot issues as needed. Maintains and follows policies and procedures, complies with local, state, and federal employment laws affecting employees and independent contractors, and assumes responsibility for ensuring that all programs are administered according to facility standards and applicable regulatory compliance.
Educational Background:
- High school diploma or GED required
- Associate’s or bachelor’s degree preferred
- An equivalent combination of relevant education and experience may be considered in place of degree
- Vocational/technical healthcare documentation/transcription training required
- RHDS or CHDS preferred
Demonstrates continued educational credits in the medical field preferred
Experience Required:
- Three to 5 years of related healthcare documentation specialist experience, preferably in an acute care setting and in a lead, supervisory and/or quality auditor capacity
Healthcare Documentation Specialist Manager
Summary:
Manages all essential functions of the Healthcare Documentation or HIM Healthcare Documentation department to ensure timely delivery of quality services. Monitors and maintains the integrity of all related systems and applications. Interviews and hires, evaluates employee performance, administers discipline, and maintains appropriate records. Monitors the Quality Assurance program and/or Clinician-Created Documentation Integrity program. Implements and oversees training programs. Oversees the use of outsourced transcription services, including contracting and technical issues. Develops, manages, and is responsible for meeting department budget. Maintains an active presence with facility and department teams related to project implementations. Responsible for continuous process improvement. Ensures compliance with state and federal laws pertaining to healthcare documentation.
Educational Background:
- Associate’s or bachelor’s degree in business, management, or health information management, or an equivalent combination of relevant education and experience
- RHDS or CHDS preferred
- RHIT or RHIA may be considered
Experience Required:
- Five years of related healthcare documentation and/or health information management experience, preferably in an acute care setting and in a supervisory or managerial capacity
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