JOB SUMMARY:
The duties of a scribe are to document the physician dictated history, physical exam, family, social and past medical history in real time in the EHR. They help to manage the non-clinic, clerical tasks of documentation including but not limited to documenting procedures, labs results, and dictated radiology. Scribes do not provide any patient care or offer any medical advice.
QUALIFICATIONS:
High school diploma or equivalent
3 or more years' experience with clinical charts/EMR/transcription, scribing or equivalent
5 or more years' experience in clinical or community health settings preferred.
Proficient in medical terminology, typing, spelling, punctuation, grammar and oral communication
Must be able to listen to complex medical information and summarize in a clear, complete and concise fashion.
Demonstrate proficient computer skills using all functions of an electronic medical record
Recognition of physical exam process and ability to record exam details
Demonstrates effective communication skills: oral and written
Effective organization skills and demonstrates ability to provide legible, accurate notes
Previous experience with health EMR systems and ability to follow and record in EMR
Professional, friendly demeanor and recognition of privacy considerations for patients and families
Ability to multi-task efficiently and effectively
Must be able to act calmly and effectively in a busy or stressful situation
Must be able to establish and maintain effective working relationships with managers and peers
ROLES & RESPONSIBILITIES:
Accompany medical provider into the patient examination room and thoroughly document (into the EMR) the medical visit and procedures as they are being performed by the provider, including but not limited to:
Patient medical history and physical exam
Procedures and treatments performed by the healthcare provider
Patient education and explanations of risks and benefits
Provider-dictated diagnosis, prescriptions, orders, referrals and instruction for patient or family members for self-care and follow up
Dictation/faxing/phone calls and clerical tasks to assist the medical provider
Assist in review and correction of medical documentation under the direction of the provider
Maintain professional appearance and conduct at all times