Neurosurgery Medical Scribe — Precision Documentation Pro

The primary role of the Medical Scribe is to relieve the practitioner of clerical and secretarial duties; thus allowing the practitioner to focus more directly on clinical care. The scribe is an unlicensed individual and exclusively non‑clinical. They do not examine patients and do not engage in any type of patient care. A scribe’s role is limited to documentation and efficiency management for the practitioner. Must be able to travel to our satellite offices (except Yuma).

Position Duties

• Assists the practitioner in navigating the Electronic Health Record (EHR) and may locate information for review as requested by the practitioner (i.e., previous notes, reports, test results, and laboratory results). Also, may research information requested by the practitioner.
• Accompanies the practitioner upon patient interview and examination and they do not interject their own observations or impressions.
• Documents the practitioner dictated patient history, including history of present illness; review of systems; past medical and surgical history; family and social histories; and medications and allergies.
• Documents physical examination findings and procedures as performed by the practitioner.
• Documents the results of laboratory and radiographic studies as dictated by the practitioner.
• Documents the correct time of patient care related activities, including practitioner to practitioner communication, family communication and re‑examination of the patient.
• Ensures the practitioner reviews all documentation completed by the Scribe when the patient encounter has concluded. This includes making any necessary amendments and signing the chart. The practitioner is ultimately responsible for documentation of the patient’s encounter.
• Make "chart rounds" with the practitioner to review patient status, delays, and any other care‑related issues.
• Ensures authentication takes place before the Practitioner and scribe leave the patient care area and that all orders for patient care are communicated by the practitioner.
• Performs miscellaneous job related duties as requested.

Position Qualifications

Education

1. High school diploma or equivalent. Required
2. Completion of college level courses or current healthcare student (i.e., mid‑level provider, nursing, healthcare administration, etc.). Preferred

Experience

1. Minimum of 2 years medical experience in a hospital setting or a private practice. Preferred
2. Experience and understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Required
3. Previous experience with or ability to translate medical abbreviations into their expanded forms. Required
4. Experience in a surgical specialty. Preferred

Special Skills

1. Ability to multi‑task and consistently communicate in a professional manner including writing routine reports and correspondence; proficient in typing and good at spelling, punctuation, grammar, and oral communication. Ability to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Required
2. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self‑motivated. Must be discreet, tactful, and modest in performance of duties. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Required
3. Ability to learn and use all functions of electronic medical record software and transcription software. Maintain and demonstrate an understanding of the team approach to patient care and documentation. Required
4. Punctuality and preparedness for all shifts and work‑related activities. Required
5. Ability to check and respond to all correspondence, including email, phone calls or text messages in a timely manner. Excellent and legible penmanship. Required

Physical Requirements & Occupational Exposure/Risk Potential

1. Physical Requirement - Feeling (sensing textures and temperatures) - Occasionally
2. Physical Requirement - Fine Motor Skills (pinching, gripping, etc.) - Constantly
3. Physical Requirement - Hearing - Constantly
4. Physical Requirement - Pushing/pulling - FrequentlyPhysical Requirement - Reaching - Occasionally
5. Physical Requirement - Sitting - Frequently
6. Physical Requirement - Standing - Frequently
7. Physical Requirement - Stooping/crouching/kneeling/crawling - Occasionally
8. Physical Requirement - Talking - Occasionally
9. Physical Requirement - Walking - Frequently
10. Physical Requirement - Near Vision - Constantly
11. Physical Requirement - Far Vision - Occasionally
12. Physical Requirement - Color Discrimination - Occasionally
13. Physical Requirement - Use of keyboard, mouse and/or computer equipment - Constantly
14. Physical Requirement - Lift up to 35 pounds without assistance - Occasionally
15. Occupational Exposure/Risk Potential - Inside office environment - Applicable
16. Occupational Exposure/Risk Potential - Airborne communicable diseases - Applicable
17. Occupational Exposure/Risk Potential - Bloodborne pathogens or bodily fluid - Applicable
18. Occupational Exposure/Risk Potential - Fumes or airborne particles - Applicable