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Qualifications:
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- High school Graduate or Equivalent
- American Heart Association (AHA) Basic Life Support (BLS) Provider certification or American Red Cross Basic Life Support for Healthcare Providers certification
- Knowledge of medical terminology, anatomy and physiology required
- Must be able to type on a keyboard at least 40 WPM, with ability to increase speed while maintaing accuracy required
- Completion of sophomore year of college in pre-med, nursing, EMT/Paramedic, Chemistry/Biology or other professional or allied health field preferred
- Completion of Organic Chemistry and/or Human Anatomy and Physiology preferred
- Medical Terminology and Pharmacology preferred
- Intent to apply to Advanced Studies in the Medical Field is preferred
- Demonstrated experience working with medical providers and allied health professionals
- Knowledge of medical terminology, anatomy and physiology preferred
- Demonstrated ability to work well under pressure in a critical environment and maintain attention to detail in order to accurately document encounter
- Demonstrated observation, listening, interpersonal, and clarification skills in order to interact positively and productively with provider and patient
- Demonstrated knowledge of computers and technology
- Demonstrated ability to multi-task and organize
- Demonstrated excellent verbal and written communication skills
- Demonstrated strong desire to learn
- Ability to maintain confidentiality
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Duties &
Responsibilities:
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Job Summary
Under the direct supervision and presence of the Practitioner (Physician and/or Mid-level Provider), the Medical Scribe provides annotation, under their own profile, in the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations/guidelines for documentation. The Medical Scribe will be responsible for clearly recording each patient’s symptoms, history, physical exam and documenting the diagnosis. The Medical Scribe is not a direct patient care provider.
Duties
- Accompany the physician and/or mid-level provider into the patient examination area in order to transcribe findings at the bedside in real time as the provider evaluates the patient
- Documents the history of the patient’s chief complaint as given by the patient and communicated by provider
- Documents the review of systems (ROS) and physical examination as given by patient and communicated by provider
- Transcribes under the direction of provider, patient orders, including laboratory tests, imaging tests, etc
- Completes the procedure note on behalf of the provider as directed
- Looks up pertinent past medical records at the direction of the provider
- Keeps track of and enters the results of imaging studies as directed by the provider
- Enters documentation on patient progress as directed by provider
- Lists proper diagnosis as well as any discharge/follow-up instructions and prescriptions, as dictated by the provider
- Reviews the record and verifies that the documentation requirements have been met for the designated code assigned by the provider
- Follows documentation compliance standards
- Assures that the Electronic Health Record is complete and that all pertinent documentation requirements are met, including the diagnosis, disposition and patient education interventions
- Ensures the provider reviews the Electronic Health Record for accuracy. Obtains provider signature, under the provider’s profile, for each encounter
- Develop and maintain a mutually respectful working relationship with all providers
- Available for provider concerns and questions and is ready to assist in documentation at all times
- The Medical Scribe does not participate in any patient care and should refer all requests to participate in any patient care to the provider or nursing staff. Relays messages to the nursing staff, providers, techs, and/or patient to expedite patient flow throughout the department
- Performs other duties as assigned
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Other Info:
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Lifting Requirements: While performing the duties of this job, the employee is regularly required to stand and enter information into a computer system. The employee is frequently required to walk or stand for extended periods, occasionally required to sit, balance; stoop, kneel or crouch.Generally lifting objects not more than 25 lbs. and/or carrying objects weighing 10 lbs.
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