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Healthcare Documentation Specialist


A healthcare documentation specialist, sometimes known as a medical transcriptionist or a medical documentation editor, listens to a voice recording made by a physician or other healthcare professional and either transcribes the information into a captured electronic record or reviews and edits a version produced by a speech recognition technology software program for the record. Because the information becomes part of the legal medical record and may serve as the foundation for ongoing decision-making and care, the work that healthcare documentation specialists do is critical.

Editing or transcribing medical reports is highly detailed work that requires patience, focus and attention to detail. Healthcare documentation specialists need extensive knowledge of medical terminology, anatomy and physiology, medical procedures, pharmacology and other medical terms. Because medical records are confidential, transcriptionists cannot discuss the content of the reports they prepare; they must be careful to keep all recordings, paper and electronic files secure and prepared to follow federal guidelines for confidentiality, security and privacy.

Healthcare documentation specialists transcribe or edit what has been dictated. They format information according to guidelines for medical records. And they often find and question inconsistencies and inaccuracies in the physician’s verbal report or the speech-recognized document.

Some healthcare providers and facilities use voice recognition software to aid in the initial oral-to-written transcription. However, these drafts must be carefully proofed against the original recording to ensure accuracy. Further editing is always required to produce a comprehensive and accurate report.

Healthcare documentation specialists may work on a wide range of reports, including medical histories, discharge summaries, physical examination reports, operating room reports, diagnostic imaging studies, consultation reports, autopsy reports, referral letters and other documents.

Working Conditions

Many healthcare documentation specialists work as independent contractors or full- or part-time employees, often working in their own homes. Others are employed in medical offices or hospitals and may spend part of their time performing office duties in addition to documentation.

Healthcare documentation specialists who work in an office typically put in a standard 40-hour week. Self-employed workers may choose to work longer hours to increase their income, meet deadlines and balance work and family responsibilities. Healthcare documentation specialists, just as other healthcare providers, often work night and weekend shifts to ensure coverage of health care being provided to patients 24 hours a day, seven days a week and 365 days a year at hospitals, urgent care centers and other healthcare facilities.

They work with every type of healthcare provider, including physicians, nurses, physical therapists, dietitians and other healthcare workers.

Healthcare documentation specialists and editors spend the majority of their time sitting in front of a computer screen and using a headset to listen to their computer or another device that plays back digital voice recordings. A key command or foot pedal may be used to pause and restart the recording as the documentation specialist keys the words into an electronic file or edits the already-recorded document.

Documentation specialists are at risk of work-related injury, including repetitive motion injuries, eye strain, neck and back pain and other problems related to the nature of their work. There can be pressure to produce reports quickly as well, along with stress associated with ensuring that every report is complete and accurate.

Salary Range and Outlook

Salaries vary because healthcare documentation specialists may be paid by the line or they may receive an hourly rate, which may include an incentive for transcribing/editing more than the minimum. Some also receive a salary.

According to the Bureau of Labor Statistics, the median annual wage of medical transcriptionists was $34,890 in May 2015. The median annual wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $21,600, and the top 10 percent earned more than $50,230.

Because of changes in technology, employment is expected to decline 3% between 2014 and 2024. Transcriptionists who graduate from a training program and those with experience in electronic health records (EHR) management, training and quality assessment are likely to find a job more easily.

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About a Career as a Health Care Documentation Specialist

About Health Care Careers

Note: The Association for Healthcare Documentation Integrity reviewed this career profile.

Academic Requirements

Healthcare documentation specialists need to be able to type accurately and quickly but the even greater challenge for this career is mastering complex medical terminology and critical thinking skills to determine the accuracy of the reports and follow established protocols to deal with inaccuracies.

Students in this field study medical language, anatomy and physiology, disease processes, laboratory terminology, medical procedures, instruments, equipment, pharmacology and other words frequently used in medical reports. They build a library of reference books and online databases, which they use frequently throughout their career. They also must have good command of English grammar, spelling and punctuation. Computer and Internet skills are also necessary.

Training is available at many community colleges and vocational schools and through online education programs. Programs vary in length from 10 months to two years. The Association for Healthcare Documentation Integrity and the American Health Information Management Association oversee and approve industry training programs in healthcare documentation and medical coding. The Association for Healthcare Documentation Integrity maintains a list of approved schools.

Graduates from approved schools are generally better prepared to sit for the registered medical transcriptionist credential, a benchmark that demonstrates job readiness to industry employers. Registered healthcare documentation specialists with a minimum of two years experience can take the exam to become certified healthcare documentation specialists.