Scribe

Job Description

Job Description

Job Title: Medical Scribe

Qualifications: At least 1 year of previous Medical Scribe experience. EPIC highly preferred. Prior courses in medical terminology preferred. Able to type at least 60 wpm. Have some experience in office management setting. 

Skills or Other Qualifications: Excellent communication skills, basic knowledge of computers, strong interpersonal skills, ability to work in a team environment, flexibility to travel to different office locations.

Essential Responsibilities:

• Accompany the physician and/or mid-level provider into the patient examination area in order to transcribe findings in real time as the provider evaluates the patient. 
• Document history of the patient’s chief complaint as given by the patient and communicated by provider. 
• Document the physical examination as given by patient and communicated by provider. 
• Transcribes under the direction of provider, patient orders, including laboratory tests, imaging tests, and medication orders
• Looks up pertinent past medical records at the direction of the provider. 
• Keeps track of and enters the results of imaging/lab studies as directed by the provider.
• Lists proper diagnosis and discharge/follow-up instructions and prescriptions, as dictated by the provider. 
• Assures that the EHR is complete and all pertinent documentation requirements are met. 
• Retrieve completed lab results. 
• Be involved in special projects as needed.
• Provide some patent education such as inhaler technique and Epipen techniques, etc. 
• Create letters and forms for patients and providers as needed.

Qualifications:

• 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. 
• Strong 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.
• Mathematical Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Have the ability to compute ratio and percent.
• 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.
• 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 be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards 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 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.