VISHNU M
Medical Secretary / Medical Scribe
Profile summary
10+ years of healthcare documentation experience supporting Cardiology and Internal Medicine consultants across outpatient and inpatient settings. Perform real-time clinical documentation, Cerner EMR data entry, order documentation, and diagnostic report integration in compliance with DOH Abu Dhabi and HIPAA standards. Demonstrate advanced proficiency in Cerner EMR workflows, along with SAP, Malaffi, NPCM, TAMM, Vue PACS, and OpenJet, delivering accurate patient records and optimized clinician workflows in high-volume hospital environments.
Career highlights
Managed High-Volume Documentation: Managed documentation for 50–60 inpatient and outpatient cases daily, ensuring accuracy and timely turnaround.
Integrated Diagnostic Investigations: Integrated diagnostic investigations, laboratory, and radiology results into patient records.
Key skills
Professional experience
• Perform real-time medical scribing for Cardiology and Internal Medicine consultants, documenting patient histories, examinations, diagnoses, investigations, and treatment plans in Cerner EMR and SAP • Create and finalize clinical documentation including discharge summaries, progress notes, operative notes, referral letters, and medico-legal reports • Integrate diagnostic investigations (ECG, echocardiography, stress tests, Holter monitoring, ABPM, ELR, cardiac catheterization), laboratory, and radiology results into patient records • Manage documentation for 50–60 inpatient and outpatient cases daily, ensuring accuracy and timely turnaround • Execute medication ordering and reconciliation through NPCM • Prepare medical certificates, sick leave, escort letters, and referrals in line with DOH and hospital policies • Process insurance pre-authorizations and approvals for internal medicine and cardiology admissions, investigations, and procedures • Operate and optimize Cerner, SAP, Malaffi, Vue PACS, OpenJet, and TAMM • Train clinicians and new hires on EMR workflows and documentation standards • Lead Cerner Super User operations, configuring workflows, enabling clinician adoption, and resolving system and user issues • Maintain compliant inpatient and outpatient medical records aligned with DOH Abu Dhabi and HIPAA
- Perform real-time medical scribing for Cardiology and Internal Medicine consultants, documenting patient histories, examinations, diagnoses, investigations, and treatment plans in Cerner EMR and SAP
- Create and finalize clinical documentation including discharge summaries, progress notes, operative notes, referral letters, and medico-legal reports
- Integrate diagnostic investigations (ECG, echocardiography, stress tests, Holter monitoring, ABPM, ELR, cardiac catheterization), laboratory, and radiology results into patient records
- Manage documentation for 50–60 inpatient and outpatient cases daily, ensuring accuracy and timely turnaround
- Execute medication ordering and reconciliation through NPCM
• Transcribe and upload physician-dictated patient histories, diagnoses, treatment plans, and follow-up notes into EHR systems with high accuracy • Structure and paste clinical documentation within EHR platforms, ensuring correct encounter mapping and provider attribution • Edit and validate speech recognition–generated reports, correcting medical terminology, grammar, formatting, and clinical context • Perform quality checks to meet accuracy and turnaround time benchmarks • Maintain strict HIPAA-compliant documentation practices and patient data confidentiality • Stay aligned with clinical documentation standards and medical best practices to ensure consistency and quality
- Transcribe and upload physician-dictated patient histories, diagnoses, treatment plans, and follow-up notes into EHR systems with high accuracy
- Structure and paste clinical documentation within EHR platforms, ensuring correct encounter mapping and provider attribution
- Edit and validate speech recognition–generated reports, correcting medical terminology, grammar, formatting, and clinical context
- Perform quality checks to meet accuracy and turnaround time benchmarks
- Maintain strict HIPAA-compliant documentation practices and patient data confidentiality
• Transcribed U.S.-based physician dictations including operative reports, discharge summaries, pathology reports, and consultation notes • Proofread and edited medical documentation to ensure accuracy and compliance with industry standards • Provided real-time quality feedback to transcription editors to reduce recurring errors • Mentored and trained medical transcriptionists on accuracy, productivity, and compliance standards
- Transcribed U.S.-based physician dictations including operative reports, discharge summaries, pathology reports, and consultation notes
- Proofread and edited medical documentation to ensure accuracy and compliance with industry standards
- Provided real-time quality feedback to transcription editors to reduce recurring errors
- Mentored and trained medical transcriptionists on accuracy, productivity, and compliance standards
• Execute U.S. healthcare backend operations including claims processing, reports handling, and electronic remittance management • Review and resolve discrepancies in patient records, claims, and insurance documentation • Conduct payer outbound calls (semi-voice) to validate claim status and documentation requirements. Document claim updates and resolutions accurately within healthcare systems
- Execute U.S. healthcare backend operations including claims processing, reports handling, and electronic remittance management
- Review and resolve discrepancies in patient records, claims, and insurance documentation
- Conduct payer outbound calls (semi-voice) to validate claim status and documentation requirements. Document claim updates and resolutions accurately within healthcare systems