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JOB SUMMARY
Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift.
The primary goal is to increase the efficiency and productivity of the physician.
It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state and federal guidelines for documentation into the electronic health record system.
The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis.
This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front office staff.
JOB DUTIES AND RESPONSIBILITIES
The primary role of the Medical Scribe is to assist the clinician with documentation of each patient’s medical chart during his or her visit.
Accompanies the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
Documents any procedures performed by the clinician or nurses, on the electronic medical chart.
Is an expert in the use of various templates and documentation techniques available in the EHR system, and use these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
Transcribes any consultations or discussions with family members and/or the clinician.
Completes the patient’s chart by transcribing results of any labs, x-rays, or other evaluations.
In doing so, the scribe continuously checks on the progress of this data in order to get the patient’s workup complete so that the clinician is able to make his or her decisions regarding that patient.
Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
Other duties as assigned.
Optional Trainable Skills
A Scribe can be trained to perform vitals, room patients, handle Patient Portal tasks for your assigned provider, chart abstraction, and assisting in other departments such as HIS, or Radiology.
KNOWLEDGE, SKILLS, AND ABILITIES
Recognition of physical exam process and ability to record exam details quickly and accurately.
Must be able to listen to complex medical information and summarize in a clear, complete and concise fashion.
Strong attention to detail.
Computer proficiency in Windows environment and ability to quickly learn new applications.
Ability to communicate effectively in the English language in person, by phone and in writing.
Typing 45 WPM or greater.
EDUCATION & EXPERIENCE
High school diploma or equivalent.
One year experience in healthcare field or minimum 2 years of college education.
PREFERRED QUALIFICATIONS
2-4 years of college education desired with Medical Terminology, Anatomy and Physiology coursework/degree.
Experience working in an outpatient clinic or doctor’s office.
Medical Transcriptionist experience.
Typing 60 WPM or greater.
BENEFITS
Competitive Wages
Medical Insurance
Dental Insurance
Vision Insurance
403 (b) Retirement Plan with matching employer contribution
Long-term Disability coverage
Accidental Death and Dismemberment
Life Insurance
Flexible Spending Account
Paid Vacation
Paid Holidays
CME with stipend
Employee Assistance Program
Jury Duty Pay
Bereavement Pay
Health Club Membership Discounts
Prescription Discount Program
529 College Savings Plan
Educational Reimbursement
Free Gym membership to Specified club
Free subscription based App for Meditation and Sleep
Free Teledoc service for benefit eligible employees
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