Description

SUMMARY

The Medical Scribe is responsible to assist the clinical practitioner with documentation of each patient’s medical chart during or after consultation or examination. Assumes responsibility and is accountable for adherence to WC policies and procedures, as well as all applicable federal and state laws as they pertain to healthcare and employment.

ESSENTIAL DUTIES

• Under the direction of the physician, transcribes patient orders, including laboratory tests, imaging tests, medications, etc.
• May accompany the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
• Completes the patient’s chart by summarizing consultation and or examination, listing all proper diagnoses as well as any follow up instructions. Monitors chart progress to ensure workup is complete and the practitioner is able to make timely decisions regarding the patient’s care.
• Navigates the EMR to look up pertinent past medical records. Retrieves, organizes, prioritizes, stores, and maintains transmittable information utilizing electronic technology.
• Responsible for protecting Personal Health Information (PHI) and maintaining compliance with WCs Privacy Policy. Uses the minimum PHI necessary when completing assignments.
• Promotes, establishes, and maintains open and effective communications with all members of WC.

SECONDARY DUTIES

• Pre-loads new patient charts and uploads images into the EMR.
• Participates actively and helpfully in special committees as assigned by management and/or physicians.
• Completes competency and compliance training as assigned.
• Any other duties as defined by management or physicians.

Requirements

EDUCATION AND EXPERIENCE

Bachelor’s Degree (complete or in progress) in science or healthcare related field preferred, or equivalent combination of education and/or experience. Education and/or work related experience should be within the discipline of healthcare.

COMPETENCIES

• Strong computer, organizational, and time management skills to ensure maximum productivity.
• Advanced language and grammar skills both verbal and written, and knowledge of medical terminology.
• Exceptional interpersonal communication skills with the ability to apply common sense; to carry out instructions; write reports; and speak clearly to patients, employees physicians, and management.
• Ability to deal with moderately complex problems involving multiple facets and variables in non-standardized situations.
• Ability to work with minimal supervision while performing duties.

WORK ENVIRONMENT AND PHYSICAL DEMANDS

This job operates in a professional medical office environment. Requires the ability to work under pressure and with a diverse population including staff, physicians, patients, vendors, and other members of the public on a regular basis. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. This position may be exposed to contagious diseases; bodily fluids including blood; toxic substances; medicinal preparations and other conditions common to a clinical environment.

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 essential duties.

• Constantly required to talk, hear, and/or communicate, convey or exchange information in a clear and concise manner.
• Constantly requires close visual acuity to perform an activity such as viewing a computer terminal and reading technical procedures.
• Constantly uses arms, hands and fingers for grasping, pushing/pulling, twisting/turning of wrists, and manipulating in the performance of various clerical duties such as typing, writing, and maintaining files; and/or to operate medical and technological equipment.
• Frequently required to stand, walk, and/or move about the office to assist physicians, patients, and to accomplish tasks.
• Frequently required push, pull, reach, and/or transport supplies and or equipment to various locations within the office. (10-50 pounds.)