health records management
The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.
Medical transcriptionists interpret dictated information from the doctor or other healthcare professionals and convert it into documents. They create, format and edit medical records for patients based on the provided data and take care to apply punctuation and grammar rules.
Competences and skills
35 ESCO relationsEssential knowledge 4 competences
Occupation specific
0 competencesNo competences in this bucket.
Sector-specific
1 competenceCross-sector
3 competencesdatabase
The classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented databases and full text databases.
digital
grammar
The set of structural rules governing the composition of clauses, phrases, and words in any given natural language.
medical terminology
The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.
Essential skills and competences 11 competences
Occupation specific
2 competencesedit dictated medical texts
Revise and edit dictated texts used for medical records purposes.
transcribe medical data
Listen to the recordings of the healthcare professional, write the information down and format it into files.
Sector-specific
4 competencesarchive healthcare users' records
Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.
maintain healthcare user data confidentiality
Comply with and maintain the confidentiality of healthcare users` illness and treatment information.
manage digital archives
Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.
digital
use electronic health records management system
Be able to use specific software for the management of health care records, following appropriate codes of practice.
digital
Cross-sector
5 competencesapply grammar and spelling rules
Apply the rules of spelling and grammar and ensure consistency throughout texts.
apply organisational techniques
Employ a set of organisational techniques and procedures which facilitate the achievement of the set goals set such as detailed planning of personnel's schedules. Use these resources efficiently and sustainably, and show flexibility when required.
comply with legislation related to health care
Comply with the regional and national health legislation which regulates relations between suppliers, payers, vendors of the healthcare industry and patients, and the delivery of healthcare services.
execute working instructions
Understand, interpret and properly apply work instructions regarding different tasks in the workplace.
use word processing software
Use computer software applications for composition, editing, formatting, and printing of any sort of written material.
digital
Optional knowledge 5 competences
Occupation specific
0 competencesNo competences in this bucket.
Sector-specific
2 competencesadministrative tasks in a medical environment
The medical administrative tasks such as registration of patients, appointment systems, record keeping of patients information and repeated precribing.
professional documentation in health care
The written standards applied in the health care professional environments for documentation purposes of one`s activity.
Cross-sector
3 competenceshealth care system
The structure and function of health care services.
human anatomy
The dynamic relationship of human structure and function and the muscosceletal, cardiovascular, respiratory, digestive, endocrine, urinary, reproductive, integumentary and nervous systems; normal and altered anatomy and physiology throughout the human lifespan.
medical informatics
The processes and tools used for the analysis and dissemination of medical data through computerized systems.
digital
Optional skills and competences 15 competences
Occupation specific
0 competencesNo competences in this bucket.
Sector-specific
9 competencescollect healthcare user's general data
Collect qualitative and quantitative data related to the healthcare user's anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.
display medical problems
Emphasize significant medical issues in a way that the attention of any healthcare professional using the record is directed on them.
identify patients' medical records
Locate, retrieve and present medical records, as requested by authorized medical personnel.
participate in medical records' auditing activities
Assist and help with any requests arisen during audits related to the archiving, filling and processing of medical records.
perform backups
Implement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integrity during system integration and after data loss occurrence.
digital
perform clinical coding procedures
Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.
review patient's medical data
Assess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.
transfer medical information
Extract information from a patient's notes and enter them in a computer programme.
digital
work in multidisciplinary health teams
Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.
Cross-sector
6 competenceshandle paperwork
Handle work-related paperwork ensuring that all relevant requirements are met.
liaise with typists
Give instructions to typists about the addressees, the appropriate format, the number of copies required, etc. for them to type the final documents.
manage digital documents
Manage various data formats and files by naming, publishing, transforming and sharing files and documents and transforming file formats.
digital
process data
Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.
digital
use databases
Use software tools for managing and organising data in a structured environment which consists of attributes, tables and relationships in order to query and modify the stored data.
digital
use shorthand
Apply shorthand as a method to capture spoken words into written form. Use shorthands in written texts to reflect acronyms and relevant information required to be expressed in such fashion.