Description

Outline of Essential Functions :

• Scribes accompany the provider upon patient interview and examination.
• Scribes document the provider dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
• Scribes document physical examination findings and procedures as performed by the provider.
• Scribes document the results of laboratory and radiographic studies as dictated by the provider.
• Scribes document the correct time of patient care related activities, including provider-to-provider communication, family communication and re-examination of the patient.
• When the provider concludes the patient’s encounter, the provider will review all documentation completed by the scribe, make any necessary amendments and sign the chart.

The provider is ultimately responsible for documentation of the patient’s encounter.

• The provider and the scribe will make chart rounds to review patient status, delays and any other care-related issues on an as needed basis.
• The provider and not the scribe must communicate all orders for patient care unless the scope of the scribe allows for verbal order communication

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.
• Must comply with Scribe Policy and Procedure .

Qualifications

Minimum Experience Required

• Medical terminology knowledge with previous experience working in the medical field
• CMA / LPN
• Certified Medical Scribe

Minimum Experience Preferred

• College students working on a medical degree
• Previous medical scribe experience

Minimum Education Required

High school diploma

Minimum Education Preferred

Medical Scribe Certification

Required Skills / Abilities

• Advanced Computer Skills
• Excellent written and verbal communication skills
• Strong organization, multitasking and time management skills

Shift

Shift Details

First

Type

Regular

Last updated : 2024-05-08