Description

General Summary: A nonexempt position responsible for scribing office visit notes for physicians, as well as gathering information in exam rooms and putting it into medical reports, correspondence, and other administrative material, which typically become part of patients’ permanent files. This is done in clinic. 

Essential Job Responsibilities:

1. Gathers information while in the room with the doctor and the patient.
2. Edits as necessary for grammar and clarity.
3. Able to gather a variety of documents, including discharge summaries, history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters. 
4. Returns transcribed documents to the physicians or other health care professionals for review and signature or correction.
5. Other duties as assigned such as receiving patients, faxing, scanning, mailing letters, answering the telephone, and handling mail.
6. Input ICD-10 codes, CPT codes, and modifiers as required for accurate claims billing.

Places all orders essential to patient care such as prescriptions, therapy, and further diagnostic testing/imaging. 

Requirements

1. Knowledge of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments (training will however be obtained on the job).
2. Knowledge of how to translate medical jargon and abbreviations into their expanded forms using electronic and printed medical reference materials.
3. Knowledge of medical record protocols and legal and ethical requirements related to keeping patient information confidential.

Skills:

1. Skill in spotting mistakes or inconsistencies in a medical report and checking to correct the information.
2. Skill in following medical record style standards.
3. Skill in keeping up to date with medical field changes.
4. Skill in professional writing. College level writing preferred.

Abilities:

1. Ability to understand and question patient assessment and treatment notes to reduce the chance of patients receiving ineffective or even harmful treatments. Ensures high-quality care.
2. Ability to stay current with medical scribe equipment as the technology changes through ongoing research and education.
3. Ability to communicate effectively with physicians and other health care professionals related to transcription questions and concerns.
4. Ability to type quickly, 45 WPM required.
5. Ability to handle high volume, fast paced, and sometimes high stress levels.