Scribe - Lead

Medical Scribe

Provide administrative support to facility physician to ensure efficient dictation of patient notes and situations.

• Accompany the physician during examination of the patient.
• Accurately document the physician dictated patient history, history of present illness, pertinent findings, mental status examination, medications and allergies.
• Accurately document the results of laboratory and radiographic studies as dictated by the physician. Accurately document the diagnoses, procedures, risk factors, and plans as dictated by the physician.
• Uses the team approach to patient care and documentation.
• Ensures all orders for patient care are communicated by the physician and not the Scribe.
• Complete and present the medical record in collaboration with the physician.
• Responsive to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician, ancillary hospital staff.
• Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
• Maintain confidentiality and privacy in accordance with governing HIPAA regulations.
• Treat all information, data and training materials utilized in the scope of the Scribe position with complete confidentiality and security.
• Cooperates fully with all risk management activities and investigations.
• Adheres to policies and procedures regarding medical terminology and approved abbreviations.

Education/Experience/Skill Requirements:

• High school diploma or equivalent required.
• One or more years' administrative/scribe experience required.