Medical ScribeAccurately and thoroughly document medical visits and procedures as they are being performed by the physician.Essential FunctionsDocumentation includes but is not limited to:Patient medical history and physical examProcedures and treatments performed by healthcare professionals, including nurses and physician assistantsPatient education and explanations of risks and benefitsPhysician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-upPrepare referral letters as directed by the physicianDictation/faxing/phone calls and clerical tasksResearch contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assignedSpot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errorsEnsure documents 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. Alert physician when chart is incompleteComply 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 confidentialCollect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submissionProofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammarOther duties may be assignedSkills/ExperienceMinimum one year of Scanner experienceKnowledge of medical terminology and EMR systems.
Familiarity with health care systems, regulations, policies, and functions. Understanding of documentation standardsSkill in reading and documenting medical ordersSkill in handling a number of tasks simultaneouslyEducation/RequirementsCandidate must possess certification and at least 1 full year of experience. Strong EMR skills required as well as communication and math skillsEnvironmental/Working ConditionsMedical exam/treatment rooms and medical officesControlled lighting, acoustics, air quality and room temperature settingsEnvironmental hazards may be unpredictable including exposure to communicable diseases and biohazardsPhysical DemandsRequires standing and walking for extensive periods of timeOccasionally requires lifting and carrying items weighing up to 10 poundsOccasional stress from dealing with many staff and patients