Medical Scribe

Job Description

Job Description

The Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. The Medical Scribe must be able to anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care.  Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.  The Medical Scribe be adaptable and versatile since s/he will be responsible for many tasks.

EXPECTATIONS:

• Arrives on time and adheres to set schedule
• Provides prompt medical support; promotes a smooth patient flow; collects and records data accurately 
• Participates with community-oriented activities and staff
• Consistently and openly communicates with supervisor and all staff
• Works flexible or extended hours where necessary
• Participates in health center in-services, by listening and respecting others’ ideas
• Demonstrates awareness of, and compliance with, organizational mission and objective of Camarena Health
• Abides by Rules of Confidentiality
• Use of professionalism and best efforts in the position

DUTIES and RESPONSIBILITES

1. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to: 

1. Patient medical history and physical exam
2. Procedures and treatments performed by healthcare professionals, including nurses and physician assistants
3. Patient education and explanations of risks and benefits
4. Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
5. Prepare referral letters as directed by the physician

2.     Dictation/Faxing/Phone calls and Clerical Tasks, including but not limited to:

1. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record 
2. Medical Scribes also ensure that letters are mailed or faxed daily to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.  
3. The Medical Scribe may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

3.    Oversees mistakes and inconsistencies in medical documentation, including but not limited to: 

1. Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors.  
2. All addenda 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.  
3. Alert physician when chart is incomplete. Medical Scribes must 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.
4. Data Collect, organize and catalog, including but not limited to:
   1. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
   2. The Medical Scribe assists in developing and maintaining systems to track patient follow up and compliance.
5. Trainings, Information Technology, HIPAA:
   1. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. 
   2. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
6. QUALIFICATIONS:
   1. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
   2. Language Skills:  The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able 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. 
   3. Medical Terminology: Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
   4. Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
   5. Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.
   6. Computer Skills: To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into the Electronic Medical Record, send and receive email and attachments. Must use the internet to access schedules, research information, etc. 
   7. Other Skills and Abilities: Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards Other Skills and Abilities – when accessing or communicating patient information. 

Physical Demands:

While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

Education:                                          

• High School Diploma or GED

Prior Experience:                             

• Previous experience in a health care setting as a Medical Scribe

Skills:

• Bilingual (English/ Spanish) preferred
• Quickly builds and maintains rapport with providers, and staff of differing backgrounds; team player
• Flexible: learns to function at all facilities
• Demonstrates good problem-solving skills
• Demonstrates or develops intermediate computer skills
• Telephone courtesy
• Customer-service oriented
• Proficient with modern office practices and procedures including email
• Attention to detail and excellent follow-through on work tasks
• Able to handle multiple tasks with perseverance and patience

Physical Requirements:                

• Must be able to move up to 20 pounds and push up to 50 pounds (on wheels).
• Must be able to hear adequately to auscultate B/P’s and be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must be able to have vision that is adequate to read accurately, read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.

By signing this I acknowledge that I am physically and mentally capable to perform all the services required by this job description, with, or the professional staff bylaws of, the healthcare organization to which I am applying with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients.