As an unlicensed member of the team, this person is responsible for documenting the physician’s or licensed independent practitioner’s dictation and / or activities into the medical record.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND / OR LICENSURE :

1. High School Diploma or equivalent required.

PREFERRED QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND / OR LICENSURE :

1. Two years of college level coursework in applicable course of study (i.e. biology, chemistry, physics) preferred.

CORE DUTIES AND RESPONSIBILITIES : The statements described here are intended to describe the general nature of work being performed by people assigned to this position.

They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. For history of present illness, past medical history, review of systems, medications, social history, family history, allergies or other elements of the patient chart : The physician or licensed independent practitioner will elicit the information as usual and Scribes will record the information in the chart for approval.

2. The Scribe may accompany the physician or licensed independent practitioner in the patient examination area in order to transcribe a history and physical examination as given by the patient and physician or licensed independent practitioner.

3. The Scribe documents in the medical chart any procedures performed by the physician or licensed independent practitioner, or nurses.

4. The Scribe transcribes any consultations or discussions with family and / or the patient’s private physician or the on-call physician.

5. Scribes may gather laboratory results, radiology results, medical records and other data for review by the physician or licensed independent practitioner.

Data should not be entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician’s or licensed independent practitioner.

6. Scribes must continuously check on the progress of this data in order to get the patient’s workup complete so that the physician or licensed independent practitioner is able to make treatment decisions.

7. The Scribe may not provide verbal orders or relay verbal orders between the physician or licensed independent practitioner and other patient care providers.

The physician or licensed independent practitioner must communicate orders directly to other care providers.

8. Scribes can make and answer calls for the physician or licensed independent practitioner, however Scribes may not take medical data over the phone.

9. Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.

11. Scribes may print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.

PHYSICAL REQUIREMENTS : 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.

WORKING ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES :

1. Working knowledge of medical terminology and accepted abbreviations.

2. Computer proficiency and ability to quickly learn new applications.

3. Communication skills and the ability to coordinate and cooperate with multiple members of the health care team.

4. Organizational skills with focus on tracking patient care and improving patient flow.

5. Professional demeanor and recognition of privacy considerations for patients and families.

6. Typing speed of 50 wpm preferred.

7. Position is subject to core competencies and quality assurance monitoring.

Last updated : 2024-05-08