Physician Scribe

CLAIBORNE MEMORIAL MEDICAL CENTER
Job Description

PHYSICIAN SCRIBE

STATEMENT OF PURPOSE:
To provide support for the mission and vision of the hospital through your actions, attitudes, and
personal conduct as a team member of your department, an employee of the hospital, and a contributor
to the health and wellbeing of the patients we service; to provide the duties outlined in this job
description to the best of your abilities; and to strive for excellent service to your customers.

JOB SUMMARY:
Assists under the supervision of the physician in the completion of the electronic medical record.
Performs documentation of review of systems and patient exam reflecting information provided by
attending physician quickly to facilitate the flow of patients. Alerts attending physician of returned
results of diagnostic testing for their review.

GENERAL DUTIES:
1. Support your manager and administration in the implementation of the hospital’s mission,

vision, and overall goals.
2. Assist your department in providing efficient and effective patient care by actively participating

in your department meetings, available educational events, personal performance evaluations
and focused counseling opportunities.

3. Promote high standards of performance by exhibiting compassion and professionalism at all
times and by being responsible for your actions, attitude, and body language.

4. Communicate in a timely and effective manner using multiple communication mediums. This
includes notes, e-mails, phone calls, one-on-one interaction, and participation in meetings.

5. Support performance improvement monitoring by collecting data, reporting incidents,
identifying patient care problems and providing performance information to your manager.

6. Assist your manager in meeting departmental budget goals, identifying capital equipment
needs, and developing new strategic goals for the department.

7. Follow all departmental and hospital policies. Request clarification and guidance if needed.
8. Manage your time to assure you clock in and out as scheduled, complete your assignments

within the scheduled timeframe, and minimize changes in the departmental work schedule.

QUALIFICATIONS:
1. High school diploma or equivalent.
2. Knowledge of medical terminology conveyed by physician during exam and/or review of

systems. Preferred, but not required, completion of medical terminology course and
anatomy/physiology course.

3. Ability to type words and numbers quickly and accurately. Preferred, but not required,
completion of computer and/or keyboarding course.

4. Required to attend all mandatory inservices including departmental meetings.
5. Required to participate in monthly PI.
6. Required to have basic computer knowledge.
7. Required to have the ability to communicate effectively in English, both written and verbally.
8. Required to pass pre-employment drug screen and random drug screens.

Physician Scribe–Emergency Department

PROFESSIONAL REQUIREMENTS:
1. Adheres to dress code, appearance is neat and clean.
2. Completes annual education requirements. (i.e., HEAT, Ethics)
3. Maintains regulatory requirements, including all federal, state, local regulations and accrediting

organization standards.
4. Maintains and ensures patient confidentiality at all times.
5. Reports to work on time and as scheduled, completes work within designated time.
6. Wears hospital identification while on duty.
8. Attends annual review and department inservices, as scheduled.
9. Uses computerized system correctly to clock in/out, request PTO, and/or review time card.
10. Represents the organization in a positive and professional manner.
11. Actively participates in performance improvement and continuous quality improvement (CQI)

activities.
12. Complies with all organizational policies regarding ethical business practices.
13. Communicates the mission, ethics and goals of the hospital, as well as the focus statement of

the department.

JOB KNOWLEDGE:
1. Knowledge of standard precautions used when accompanying physician at patient’s bedside for

examination and/or review of systems.
2. Knowledge of aseptic and sterile technique when accompanying physician during treatment at

the patient’s bedside.
3. Knowledge of electronic health record and record systems used throughout clinic.
4. Knowledge of medical terminology conveyed by physician during exam and/or review of

systems. Preferred, but not required, completion of medical terminology course and
anatomy/physiology course.

5. Proficient in typing, spelling, punctuation, and grammar. Preferred, but not required,
completion of computer and/or keyboarding course.

6. Knowledge of layout of supply area in order to quickly assist physician with supply needs.



SPECIFIC DUTIES:
1. Assists physician requiring scribe with accurate documentation of assessments, examinations,

and treatments to complete the electronic health record in a timely manner.
2. Retrieves historical information related to previous emergency care, hospitalization, and/or

diagnostic studies using the electronic health record system.
3. Notifies physician of unsigned orders placed by nursing staff before chart is closed and

removed from the active patient list.
4. Demonstrates an ability to be flexible, organized, and functions under stressful situations.
5. Notifies physician of returned diagnostic testing in a timely manner.
6. Reports clear, concise messages from staff, patient, and/or patient family members to the

physician in a timely manner.
7. Reports to physician immediately upon completion of patient exam and review of systems,

allowing the physician to then sign off or agree with scribe attestation.
8. Willingness to work with realization that errors may have serious consequences for patients.
9. Patience and tact in dealing with patients, their families, and visitors.
10. Willingness to perform a variety of simple repetitive tasks.
11. Assumes additional duties as assigned by the physician requiring scribe services and/or

department manager.

Physician Scribe–Emergency Department

PHYSICAL DEMANDS:
1 Good physical and mental health.
2. Must be able to withstand strenuous physical activity.
3. Walking and/or standing approximately 50% of the day.
4. Sitting approximately 50% of the day.
5. Must be able to lift up to 30 lbs. (no less than 20 lbs.) less than 20% of the day.
6. Must be able to bend, stoop, kneel, and reach over the head less than 50% of the day.

DISCLAIMER:
This is not an exhaustive list of all responsibilities, skills, duties, requirements, efforts or working
conditions associated with the job. While this is intended to be an accurate reflection of the current
job, management reserves the right to revise the job or to require that other or different tasks to be
performed when circumstances change.

RESPONSIBILITY:
The physician scribe is directly responsible to the Nurse Manager.

DIRECT REPORTS:
None