Medical Scribe-Dr. J. Wood BRFMC

JOB PURPOSE & MISSION

Transcribes medical reports dictated by physicians for inclusion in the medical records and for transmission to physicians or other medical care facilities.

Essential Job Functions include, but are not limited to:

1. Transcribes a variety of medical reports including histories, physicals, consultations, progress notes, operative/procedure reports, discharge summaries, transfer summaries, and other medical reports.

• Transcribes medical dictation accurately with less than 5% error noted in sampling of reports.
• Transcribes dictation in order of priority as assigned by the supervisor.
• Always safeguards and preserves the confidentiality of records in accordance with departmental policy.
• Demonstrates the ability to maintain all equipment in safe and proper working condition.
• Maintains an acceptable base level of minutes typed per day, according to department standards.

2. Ensures accuracy of processed reports as to spelling, punctuation, sentence structure, appropriate format and medical terminology.

• Demonstrates a thorough working knowledge of medical terminology.
• Obtains and records patient identification and physician identification for each report transcribed with 100% accuracy.
• Consistently proofs and checks work for completeness, accuracy and format.

3. Scribes for physicians during examinations and treatments of patients.

• Accurately gathers information and documents the treatment process in electronic health records system

4. Performs all other duties as assigned.

JOB REQUIREMENTS

Experience

Required:None

Education

Required:Must be enrolled in a four-year undergraduate program majoring in pre-med or related field.

Certifications & Licensure

Required:None

Special Skills or Knowledge

Required:Knowledge of English grammar, spelling and medical terminology

HIPAA & SAFETY REQUIREMENTS

HIPAA - Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records without limitation both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, medical records related to quality data, patient financial information, patient billing 3rd party, patient related complaints, information related to patient location, religious beliefs and/or public health records.

SAFETY - Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wastes, sharps and linen, PPE, exposure control plans, hand washing, environment of care, patient identification, administers/collects medications/blood order, transports/monitors or observes patients with infusion pumps, and monitors clinical alarms.

PERFORMANCE CRITERIA & STANDARDS

Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
• Takes initiative in living our Everyday Excellence values and vital signs.
• Takes initiative in identifying customer needs before the customer asks.
• Participates in teamwork willingly and with enthusiasm.
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
• Keeps customers informed, answers customer questions and anticipates information needs of customers

Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.
• Maintains accurate and reliable patient/organizational records.
• Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

Personal Achievement - Employee demonstrates initiative in achieving work goals and meeting personal objectives.

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
• Upholds the ethical standards of the organization.

Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
• Initiates or redesigns to continuously improve work processes.
• Contributes ideas and suggestions to improve approaches to work processes.
• Willingly participates in organization and/or department quality initiatives.

Cost Management - Employee demonstrates effective cost management practices.

• Effectively manages time and resources.
• Makes conscious effort to effectively utilize the resources of the organization - material, human, and financial.
• Consistently looks for and uses resource saving processes.

Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
• Employee proactively reports errors, potential errors, injuries or potential injuries.
• Employee demonstrates departmental specific patient and employee safety standards at all times.
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.