SUMMARY

A medical scribe is essentially a personal assistant to a physician, documenting all physician-patient encounters in real time, from the start of treatment until it ends. They gather and document information about the patient's visit to deliver the most efficient patient care possible.

• Accompany providers during patient visits to assist in documenting the provider assessment and exam
• Accurately document patient history and complaints, physical exams, assessments, diagnostic results, medical procedures, treatment plans, and medical opinions of consultants
• Interact with your provider to capture accurate diagnoses, pharmacy prescriptions and patient follow-up instructions’ communicate with other members of the healthcare team
• Assist providers in obtaining lab and radiology results to help guide their patient care; schedule tests and procedures as directed; coordinate and prepare referral letters; produce reports
• Communicate with patients to discover past history and test results on patients which are critical in driving medical decisions by your provider
• Understand the flow of patient encounters in your facility to assist the care team in making patient visits as efficient as possible. Follow the progress of labs, imaging studies, and other real time patient data
• Perform a variety of other non-clinical tasks dependent on your provider’s requests
• Understand basic documentation requirements for the World Health Organization’s International Classification of Diseases (ICD-10)
• Ensure compliance on all national and local patient privacy laws including HIPAA and HITECH
• Adhere to medical facility’s compliance/confidentiality requirements and company policies and procedures
• Review and edit physician medical paperwork; Ensure medical paperwork is error-free, up-to-date, and signed by the provider
• Add all clinical data, lab findings, and physician interpretations to the EHR correctly.
• Assist with the creation and maintenance of patient tracking systems.
• Attend courses and conferences on a broad spectrum of medical disciplines.
• Performs other duties as assigned or requested

• High school diploma or GED.
• Knowledge of medical terminology and anatomy.
• Bachelor’s degree in a medical discipline is a plus.
• Prior experience in hospital scribing is a plus.

• Accurate and rapid typing skills.
• Experience with medical record software and hardware.
• Excellent linguistic and written and vocal communication abilities.
• Ability to calculate simple math & familiar with computers.
• Strong attention to detail, record-keeping, and reporting abilities.

• Charting Ability,
• Communication Skills,
• Critical Thinking, Able to Multi-Task,
• Interact Comfortably with Patients,
• Stay Organized, Be Flexible/Adaptable, Team Player,
• EMR Knowledge, Medical Terminology Understanding, Anatomy & Physiology Familiarity.

Physical Requirements:

1. Body Positions: Sitting and standing for prolonged periods.
2. Body Movements: Arm and hand dexterity.
3. Body Senses: Must have command of close and distant sight, color perception and hearing.
4. Strength: Ability to lift and move up to 25-pounds.

Working Environment:

1.Work in an office, where the climate is controlled.

2. OSHA exposure category: II

• Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
• Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
• Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.