Posted in Career Insights
what is a healthcare documentation specialist

If you’re interested in a career in the healthcare field that doesn’t require a lot of experience, you may have heard of a healthcare documentation specialist.

Also referred to as a medical transcriptionist, these specialists are responsible for transcribing a variety of patient information on behalf of a doctor or other medical professional.

So what does that kind of career entail?

Here’s a closer look at the position, including its usual requirements, duties, pay, and job outlook.

What Exactly Does a Healthcare Documentation Specialist Do?

The primary job of a healthcare documentation editor or transcriptionist is to record information from physicians to a patient record.

While some specialists do this by listening to an audio recording from the doctor and transcribing it directly, others simply edit the text produced by a speech recognition program used by the doctor.

In either case, a healthcare documentation specialist has a very important role.

Their attention to detail, focus, and knowledge of medical terminology are critical to maintaining accurate patient records while ensuring confidentiality.

Transcriptionists may not share any of the information they document and must thoroughly inspect the record for any errors or inaccuracies. 

Required Education and Experience

Education requirements for documentation specialists and transcriptionists vary widely. Some positions require a postsecondary certificate, certification, or even a bachelor’s degree.

However, many just require a high school diploma. This depends heavily on the employer and their location.

Generally, medical documentation and transcription jobs are available to those looking to change careers.

Most employees in this field either work at either a doctor’s office or hospital, while others offer their services as independent contractors.

This gives you plenty of options for starting a career in medical documentation and transcribing. 

Ideal Skills and Knowledge

While medical documentation mostly involves writing, there are several other skill sets that employers expect. 

Probably the most important is knowledge of medical terms, including things like:

  • Anatomy,
  • Physiology,
  • Pharmacology,
  • Diseases,
  • Procedures,
  • Treatments,
  • Professional slang,
  • Medical equipment,
  • Lab terminology,
  • Abbreviations,
  • Acronyms, and
  • Measurements.

A lot of this information may seem overwhelming at first. However, there are a number of ways you can learn it.

In addition, many specialists keep track of most of these things with a medical dictionary or similar aid.

These aren’t the only skills that employers are looking for. Since anything that is transcribed becomes a permanent part of the patient’s record, it is essential that specialists have great proofreading ability.

Even a single mistake can cause serious problems down the line, both for the employer and the patient.

This is why it’s important to hone your editing skills as a healthcare documentation specialist and ensure that your writing is accurate.

Typical Working Conditions and Duties

As mentioned before, healthcare documentation specialists work in a variety of settings. They often work either remotely or in a medical office.

In either case, they use a computer for most of the day, completing tasks such as:

  • Transcribing recorded notes from physicians and other healthcare professionals;
  • Compiling medical documentation such as chart notes, reports, and letters;
  • Translating abbreviated medical terms into their full names when applicable;
  • Ensuring that patient records are consistent and accurate; and
  • Editing patient reports as necessary.

Something to keep in mind is that this job requires intense focus and organization.

Many employers expect a 24-48 hour turnaround time for patient documents, which is usually stated in a healthcare documentation specialist job description.

This means you must have great time management skills and attention to detail.

Healthcare Documentation Specialist Job Pay and Outlook

Healthcare documentation specialists make a decent amount depending on their experience and location.

Data from the Bureau of Labor Statistics shows that medical records specialists make an average of $48,310 per year, or around $23.23 per hour.

The bottom 10% of workers earned just under $30,000 per year while the top 10% earned more than $74,000.

According to the BLS, the job outlook for medical records specialists is also set to grow by 7% by 2031. However, positions for medical transcriptionists are set to decline by 7%.

This is primarily due to changes in technology, since many doctors now use speech recognition programs instead of audio recordings.

Despite this change, there will still be a demand for medical documentation specialists with great editing skills since speech recognition software isn’t perfect.

Want to Learn How to Become a Medical Documentation Specialist? Enroll in Our Course!

If you are considering a career in medical or healthcare documentation but don’t know where to start, sign up for Stratford Career Institute’s medical transcriptionist course.

Our course goes through all the basics of the job, from medical terminology and style guides to proofreading and ethical considerations. To learn more, enroll today or contact us for more information.


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Become a Medical Documentation Specialist!

Become a Medical Documentation Specialist!

Explore Stratford Career Institute’s medical documentation specialist course to see if it is right for you. Enroll today!