Medical Scribe Heart and Vascular Lab

Medical Scribe, Heart and Vascular Lab

POSITION SUMMARY

• The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter

QUALIFICATIONS

1. Knowledge, Skills and Abilities

• Excellent customer service skills.
• Reads and understands the English language.
• Ability to think critically and analytically with little or no supervision.
• Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.
• Ability to process information and prioritize.
• Possesses exceptional verbal and written communication skills.
• Possesses independent work habits, is self-reliant and self-directed.
• Ability to learn, adapt, and change as required by the job functions.
• Ability to maintain absolute confidentiality of material and information accessed and reviewed.
• Basic computer literacy.
• Ability to move freely, reach, bend, and complete light lifting.
• Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines.
• Ability to maintain attendance to meet standard job practices.
• Attends 75% of scheduled unit conferences.

2. Education

• High School Graduate or GED

3. Certification

• BLS

4. Licensure

• None required, Prefer LPN or student enrolled in healthcare related course- nursing, physician assistant, healthcare administration, or pre-med.

5. Experience

• Minimum one-year experience in a healthcare related field.

6. Interpersonal skills

• Positive and effective communication skills

7. Essential technical/motor skills

8. Essential physical requirements

9. Essential mental requirements

10. Essential sensory requirements

11. Basic skills as defined by licensure/certification.

12. Proficient with computers, typing, and medical terminology.

OTHER QUALIFICATIONS

13. Exposure to hazards (body fluid exposure level)

• Level I

14. Age of Patient Populations Served

• Adults 19 - 70 years
• Geriatrics - 70 years

STANDARDS OF PERFORMANCE

CRMC employees are devoted to serving our customers – including patients, physicians, fellow-employees and our community by adhering to the Standards of Performance. We are here to make all our customers feel special.

15. Courteous – Employee is courteous in interactions with customers – patients, physicians, fellow-employees and our community.

16. Respectful and Confidential – Employee respects the rights of privacy of our patients. Ensures cultural differences are respected.

17. Responsive – Employee responds quickly, graciously and appropriately to customer needs. Employee thanks customers.

18. Gratitude and Attitude – Employee’s behavior shows that he/she believes that each of us controls our own attitude and that what is important is not so much as what happens to us, but how we choose to react to it.

19. Pride, Ownership, and Image – Employee accepts all the rights and responsibilities of being a part of the CRMC family.

20. Communication – Employee is personally accountable for positive communication with the customer – patients, family members and co-workers.

21. Teamwork - Employee contributes positively to the CRMC team and is committed to treating coworkers with courtesy, honesty and respect. Employee abides by the Time and Attendance Policy. Employee has team pride in the purpose of our work – saving lives.

JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS

Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.

1. Accompanies the physician or physician extender (P.A. and/or NP) upon patient interview and examination.

2. Prints the consult list daily, organizes all labs, radiology reports for the physician or physician extender to review.

3. Verifies patient information by interviewing patient, recording medial history, confirming purpose of consult.

4. Lists all symptoms and diagnoses including laboratory tests, mediations, orders, treatments, etc.

5. Documents the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.

6. Documents physical examination findings and procedures as performed by the physician.

7. Documents the results of laboratory and radiographic studies as dictated by the physician.

8. Documents the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.

9. Secures patient information and maintains patient confidence by completing and safeguarding medical records.

10. Serves and protects the practice by adhering to professional standards, policies, and procedures, federal, state, and local requirements.

11. Documents the plan of care and follow up needs as directed by the physician.

12. When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.

13. The physician and the Scribe will make “chart rounds” to review patient status, delays, and any other care-related issues.

14. All orders for patient care must be communicated by the physician and not the Scribe.

15. Maintain and demonstrate an understanding of the team approach to patient care and documentation.

16. Complete and present the medical record in collaboration with the supervising physician.

17. Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.

18. Participate in ongoing educational opportunities as offered in HealthStream.

19. Attend regularly scheduled staff meetings.

20. Be responsive to improvement opportunities in a positive manner.

21. Communicate in a professional and respectful manner to the supervising physician and ancillary staff.