Home   |   About AHDI   |   Shopping Cart   |   Contact Us   |   Sign In   |   Join
Under Construction - 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, 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 preferred

 

Experience Required:
  • None or minimal medical transcription experience; some organizations may require one-year 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 (RMT, RHDS, CMT, or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Vocational/Technical Healthcare Documentation/Transcription course preferred
  • Demonstrates continued educational credits in the medical field preferred

 

Experience Required:
  • More than one-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.)

 

 


Medical Scribe 

Summary:

This professional tracks with the physician on his rounds and documents medical information on behalf of the physician in real-time. The clinician may also use a digital recorder and then have his/her MT/MLS extract the information and place into the EMR or clinical system. Often scribes will perform other tasks such as clerical or otherwise.

 

Educational Background:
  • Accredited medical transcription program (RHDS, CMT, or CHDS preferred)
  • Trained as CMA, CNA, LPN, LVN, RN

 

Experience Required:
  • Medical background (medical transcription, medical assistant)

 

 


Medical Scribe - unclear if this is a different level than above

Summary: 

Creates and maintains the patient's medical record encounter in the EMR/EHR that is created under the supervision of the provider.  The scribe documents the patient encounter, including the provider's interaction with the patient, the procedures performed, the results of laboratory tests ordered, and other pertinent information. Additional functions may include (under the supervision of the provider) ordering lab/radiology studies, assisting with the patient's disposition, documenting consultations, and notifying the provider when important studies are completed. May work in an ambulatory setting, emergency room, or hospital setting. Data capture is performed real time. Remote options are sometimes available, but most often the scribe works directly with the provider in the same setting.  

 

Educational Background: 
  • High school diploma or GED required
  • Minimum two-year associate degree in the health sciences required
  • CHDS certification preferred

 

Experience Required:
  • Minimum 1-2 years’ experience as healthcare documentation specialist

 

 


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 (RMT, RHDS, CMT, or CHDS).

 

Educational Background:
  • High School Diploma or GED required
  • Vocational/technical healthcare documentation/transcription course preferred
  • 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

 

 


Healthcare Documentation Specialist 4 

Summary:

Healthcare Documentation Specialist, Level 4 transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 4 individuals possess expert knowledge in the field of healthcare documentation. Nature of work performed crosses all medical specialties in an acute care setting. Individual acts as an expert resource to others, performs QA tasks, mentor peers and/or assists with special projects. AHDI certification is required (CMT or CHDS). 

 

Remainder of job description needs to be inserted

 

  


Career Map Shortcuts

Continue Researching the Career Domains:

 
 
 
 

 

 Research Various Career Levels Across the Domains:


 

Return Back to the Career Map Homepage

Association Management Software Powered by YourMembership  ::  Legal