The Scribe will use clinical experience to efficiently accompany the Provider into patient examination rooms to transcribe complex patient history, physical exam findings, consultations, labs, x-rays and other evaluations, as stated by the Provider, directly into the medical record. The professionalism and clinical expertise of the Scribe will allow the provider to focus on the care of the patient. Responsibilities Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
Ensures medical record compliance by self-documentation attestation. Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures. Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned. Alert provider when chart is incomplete. Scribe must comply 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 confidential Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding.
Quickly assimilate new knowledge into processes and procedures. Scribes proofread and edit all the provider’s medical documents for accuracy, spelling, punctuation, and grammar. Other duties as assigned Education H.
S. Diploma - Required Work Experience Scribe experience - Required Knowledge of medical terminology - Required Licenses and Certifications Upon Hire Travel Requirements Must be able to travel between various system facilities and off-site locations as needed. - Required Qualifications Skills and Abilities Essential Technical/Motor Skills Fine motor skills required, eye\hand coordination, walk, ability to speak clearly, hear answer phone, electronic data entry.
Interpersonal Skills Displays a friendly, positive attitude and communicates with patients, families, physicians and co-workers in a professional manner. Ability to communicate in verbally and written. Essential Physical Requirements Must move, kneel, crouch, stoop, reach, stand, push, pull, and lift.
Must follow good body mechanics. Essential Mental Abilities Ability to collect thorough information regarding patient's condition and evaluate effects of care; must be able to visually inspect patient's condition. Problem solve, manipulate numbers, adaptability, interpret data, calculate, comprehend, understand, explain, assess, evaluate short term and long term memory.
Essential Sensory Requirements Ability to visually assess patient condition; must be able to communicate with patient in order to assess condition and evaluate effects of care. Visual, hearing, feeling, smell. Exposure to Hazards Body fluids, needles, cuts, blood products, back injuries and any other medical office related hazards.
Other Skills and Abilities
Full time · Days shift