POSITION: Medical Scribe
DEPARTMENT: Medical Unit
STATUS: Full-Time, Non-Exempt
POSITION SUMMARY:
Under the direct supervision of the Medical Unit Manager, the Medical Scribe performs all clerical and information technology functions for a physician in a specialty clinic setting, including primary responsibility for the operation of electronic health records and dictation.
Essential Duties and Responsibilities:
- Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present
- Greets all patients in a professional and friendly manner.
- Perform documentation in EHR software for physicians for all patients
- Handles confidential material while protecting its strict confidentiality under HIPPA guidelines
- Speak clearly and distinctly using appropriate vocabulary and grammar to obtain and convey information
- Transcribe patient orders including laboratory tests, radiology tests, medications, etc
- Attends and participates in meetings as required.
- Document any procedures performed by the physician
- List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
- Add Chief Complaints to ECW
- Other duties as assigned.
Education and Qualifications:
- High School Diploma or equivalent
- Ability to work with people of diverse cultural, educational, social, and economic backgrounds.
- Detailed knowledge of medical terminology and the ability to distinguish different exams and medical diagnoses
- Ability to work independently and a self-starter with minimal supervision
- Excellent oral and written communication skills
- Excellent organizational skills
- Computer proficiency
- They must have exceptional organizational skills with focus on tracking patient care and improving patient flow.
- Experience utilizing an Electronic Medical Records (EMR) system is highly desirable
- Bilingual preferred
- Obtain CPR within two weeks of hire
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to stand, sit, talk or listen. The employee is occasionally required to use hands to handle, or feel objects, keyboard or controls; and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
