Medical Scribe

The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient's encounter in the medical clinic.

Outline of Essential Functions:

Assigned to work with one physician per shift. Accompany the physician upon patient interview and examination. Document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Document physical examination findings and procedures as performed by the physician. Document the correct time spent on patient care related activities including physician to physician communication, family communication, and re-examination of the patient. When the physician concludes the patient's encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient's encounter. The physician and the Scribe will make "chart rounds" to review patient status, delays, and any other care-related issues.

Additional Responsibilities:

Maintain and demonstrate an understanding of the team approach to patient care and documentation. Complete and present the medical record in collaboration with the supervising physician. Be responsive to improvement opportunities in a positive manner. Communicate in a professional and respectful manner to the supervising physician and staff.

Knowledge/ Skills/ Abilities:

Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation. Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations. Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.

Minimum Position Qualifications:

Minimum one-year availability to work. Excellent and legible penmanship. Ability to multi-task and consistently communicate in a professional manner. Completion of a medical terminology course or one-year medical terminology experience in a clinical setting. Punctuality and preparedness for all shifts and work-related activities. Professional appearance is required. Ability to check and respond to all correspondence, including email, phone calls or text messages in a timely manner.

Preferred Position Qualifications:

Healthcare student - physician, nursing, physician assistant, healthcare administration, etc. College level education including health or medical related courses. Upper level knowledge of medical terminology. Upper level typing/computer skills.

Job Type:

Full-time Pay:

$23.00 per hour

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Paid time off Vision insurance

Experience:

Medical terminology: 1 year (Required)

Typing:

1 year (Required)

Medical Scribe:

1 year (Required)

Work Location:

In person