Medical Scribe
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Summary
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GENERAL SUMMARY
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The scribe accompanies and assists the physician during clinic to record all aspects of the patient encounter based on the requisite level of coding, and generate electronic documents which entails the clinic visit details. The scribe establishes and maintains effective working relationships with physicians, staff, and management. The scribe does not directly perform patient care.
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ESSENTIAL DUTIES AND RESPONSIBILITIES
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Accurately and thoroughly documents medical visits and procedures in the electronic medical record as they are being performed by the physician, including but not limited to: pertinent medical history, chief complaint, history of present illness, review of systems, co-morbid conditions, medications, allergies, physical exam, procedures and treatments performed by the physician and/or other healthcare professionals on the care team, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
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Completes data entry into relevant databases for quality improvement and research registries as appropriate.
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Searches the electronic medical record system and relevant software systems to gather and organize health information.
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Maintains relevant supplies and equipment.
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Supports and performs clerical functions as needed.
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Performs other duties and specialized tasks as assigned.
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LICENSES AND/OR CERTIFICATIONS
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Medical Scribe Certification preferred.
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MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
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Bachelor’s degree in Healthcare/Health Sciences or related field preferred.
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One year experience as a Medical Scribe preferred.
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Cerner/Powerchart electronic medical record experience preferred.
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Healthcare experience preferred.
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Pediatric experience preferred.
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Demonstrates proficiency in verbal and non-verbal communication.
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Knowledge of anatomy and physiology and general medical terminology, conditions, and interactions to effectively interact with the clinical provider during the clinical visit.
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Must be able to listen to complex medical information and summarize in clear, complete, and concise fashion.
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Possesses computer skills and typing skills >60 words per minute in order to document patient encounter in real time.
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Demonstrates ability to understand and translate medical abbreviations and smart phrases within the electronic medical record to maintain accuracy of health information.
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Interpersonal skills necessary to establish and maintain effective working relationships with physicians, staff, and management.
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Must be highly organized and possess excellent communication and analytical skills with the ability to plan, establish and maintain a professional work environment.
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Must be able to write routine reports and correspondence as needed to perform necessary job duties.
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Technical and professional knowledge and skills in use of computer hardware and software programs, including electronic medical records.
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Ability to be flexible and travel locally to multiple practice sites.
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WORKING CONDITIONS
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Expected to work in a patient care environment with minimal exposure to environmental hazards such as, but not limited to, excessive noise, dust, or extremes in temperatures. Exposure to communicable diseases and moderately adverse working conditions due to the need to perform certain patient care activities can be expected.
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PHYSICAL REQUIREMENTS
