Medical Scribe

Description

To facilitate patient flow through the practice site and aid in ensuring an accurate and complete medical record for each patient.

JOB FUNCTIONS:

• Assists the medical provider by accompanying medical provider during the medical history-taking and exam of patient; accurately and thoroughly records details of medical history and medical exam into the patient’s medical record; and coordinates departmental resources regarding tests, orders, radiology and results. 
• Tracks the orders for each patient, records results and notifies medical provider of results as it arrives. 
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. 
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc. 
• Document any procedures performed by the physician.

Requirements

Education:

• High school diploma or general equivalency diploma (GED). 
• Recent graduate of or currently attending an accredited college or university pursuing a degree in pre-med or other related field preferred OR
• Two years’ experience in a medical office preferred.
• Experience with Electronic Health Records and medical coding training or certification preferred.

Experience:

• Previous experience as a medical scribe desired.

PERFORMANCE REQUIREMENTS:

Knowledge:

• Working knowledge or ability to learn medical terminology, accepted abbreviations, and medical office procedures.
• Recognition of physical exam process and ability to record exam details in medical record.

Skills: 

• Skill in organizational matters, including time management, prioritization, multitasking, and problem solving.
• Legible handwriting and ability to accurately record information.
• Computer proficiency and ability to quickly learn new software applications.
• Organizational skills with focus on tracking patient care and improving patient flow.

Abilities:

• Ability to type using word-processing software. Able to learn/use other computer programs including e-mail, Internet, EPIC for electronic medical records.
• Ability to read, understand and follow oral and written instructions.
• Excellent communication skills and the ability to establish and maintain effective/professional working relationships with patients, physicians and other clinical staff, and the public.
• Professional demeanor and recognition of privacy considerations for patients and families.

Equipment Operated:

• Standard medical exam/office equipment, which may include computerized health information management system for medical records, etc.

Work Environment:

• Medical exam/treatment rooms setting. 
• Controlled lighting, acoustics, air quality, and temperature settings. 
• Environmental hazards may be unpredictable including exposure to communicable diseases and biohazards.

Physical Requirements:

• Involves standing and walking approximately 80 percent of the day, sitting the remainder. Some bending, stooping, and lifting up to 15 pounds.
• Repetitive motion work with keyboards and physical writing.

Safety

• All employees are responsible for complying with safe and healthful work practices as outlined in the Company's Employee Safety and Injury and Illness Prevention Program and policies and procedures specific to their department needs.