Medical Scribe

Medical Scribe

Accurately and thoroughly document medical visits and procedures as they are being performed by the physician.

Essential Functions:

1. Documentation includes but is not limited to:

Patient medical history and physical exam,

Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.

Patient education and explanations of risks and benefits.

Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up

Prepare referral letters as directed by the physician

2. Dictation/faxing/phone calls and clerical tasks.

3. Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

4. Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.

5. Ensure documents must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.

6. Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

7. Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.

8. Proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.

9. Other duties may be assigned.

Skills/Experience:

1. Minimum one year of Scanner experience

2. Knowledge of medical terminology and EMR systems. Familiarity with health care systems, regulations, policies, and functions. Understanding of documentation standards

3. Skill in reading and documenting medical orders.

4. Skill in handling a number of tasks simultaneously.

Education/Requirements:

1. Candidate must possess certification and at least 1 full year of experience. Strong EMR skills required as well as communication and math skills

Environmental/Working Conditions:

1. Medical exam/treatment rooms and medical offices.

2. Controlled lighting, acoustics, air quality and room temperature settings.

3. Environmental hazards may be unpredictable including exposure to communicable diseases and biohazards.

Physical Demands:

1. Requires standing and walking for extensive periods of time

2. Occasionally requires lifting and carrying items weighing up to 10 pounds.

3. Occasional stress from dealing with many staff and patients.