Transcript Document health information

Health Informatics
Career Responsibilities
Document information
 Obtain and record patient information
 Transcribe health information
 Complete and process insurance forms
 Follow legal guidelines for documents
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Health Informatics
Career Responsibilities
Document information
 Obtain and record patient information
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Health Informatics
Career Responsibilities
Document information
 The medical transcriptionist transcribes
health information dictated by physicians
and other healthcare professionals into the
patient’s medical record
 Requires knowledge of medical
transcription practices and
legal guidelines
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Health Informatics
Career Responsibilities
Document information
 Requires:
 knowledge of medical terminology
 understanding of anatomy, physiology, and
disease processes
 familiarity with pharmacology and laboratory
tests
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Health Informatics
Career Responsibilities
Document information
Proofread Transcribed Reports
 Evaluate punctuation
 Evaluate spelling using spell check
 Watch for sound alike words
 Ex: hear/here; sight/site
 Evaluate possible keying errors. Pay particular
attention to numbers.
 Use the print layout view to evaluate the entire
page of your document.
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Health Informatics
Career Responsibilities
Document information
 Health Insurance Specialist completes
and processes insurance forms
 Reviews charges
 Codes diagnoses and procedures
 Posts charges and payments to
patients account
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Health Insurance Claim Form
CMS-1500
 Standard claims form used to request
reimbursement for healthcare services.
 a third-party payer (insurance company) or
 government program (Medicare/Medicaid)
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Health Informatics
Career Responsibilities
Document information
 Follow legal guidelines for documents
 Maintain confidentiality of patient
information
 Ethical claims posted for insurance
reimbursement
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