Overview:
The Medical Scribe ensures accurate and timely documentation of the medical chart under the supervision of the medical provider. The Scribe assists the provider by accompanying them during the patient exam recording detailed information into the electronic medical record (EMR). The Scribe performs other related medical record or clerical duties to increase provider effectiveness, efficiency, and productivity for improved patient flow and satisfaction.
Responsibilities:
Preparing and assembling medical record documentation/charts for physician(s).
Entering the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
Ensuring medical record compliance by self-documentation of Scribe name, title and doctor working for as well as specific date and time entry.
Updating patient history, physical exam and other pertinent health information in the patient record.
Preparing and sending all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
Monitoring the duration of basic lab results and screening procedures.
Compliance with hospital and ProScribe policies, including those relating to HIPAA.
Perform other clerical duties as assigned.
Core Competencies Required:
Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.
Strong written and verbal communication skills.
Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English.
Ability to spell proofread and edit written text.
Keyboard proficiency (approximately 70 words/minute).
Ability to operate a personal computer and related software applications.
Strong attention to detail.
Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.
Ability to coordinate multiple projects and patients.
Ability to problem solve under pressure.
Ability to communicate and interact professionally with others.
Understanding of and commitment to appropriate protection of confidential patient information.
Commitment to high professional ethical standards.
Qualifications:
High school diploma required. College sophomore status or higher required. Pre-health career track preferred. Familiarity with clinical procedures and ability to demonstrate knowledge of medical terminology strongly preferred.