Medical Scribe - Surgery (Full Time)

 

Department:NursingOverall Purpose of the Position:

The Medical Scribe is responsible for accurate, thorough documentation of the clinic visit and/or procedures, as they are being performed by the physician. The primary goal is to increase the efficiency and the productivity of the physician they are working for.

 

Major Job Responsibilities:Percentage:1. Accurately and thoroughly document the patient’s medical visits and/or procedures in the electronic medical record (EMR) as instructed by the physician, including but not limited to:

• Patient medical history and physical exam
• Procedures and treatments (diagnostic findings, lab, test results, etc.)
• Consultations with other providers
• Emergency Department treatment course/Hospital Admissions information
• Patient education and explanations of risks and benefits.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up

40%2. Reviews medical documentation created and checks for errors and inconsistencies. Discusses findings with physician. Alerts physician when chart is incomplete. Demonstrates a professional, non-intrusive interaction with patients.30%3. Complies with standards of the electronic medical records software, legal and ethical requirements for preparing medical documents and keeping patient information confidential. Completes assigned tasks in a timely manner to allow physician to sign off and lock clinical note(s) for processing.
20%4. All other miscellaneous responsibilities and duties as assigned.5%5. Demonstrates quality work, completes assignments on a timely basis, and makes decisions within limits of authority. Takes initiative in problem solving, maintains confidentiality of patient and company information, and interacts with patients, co-workers, and management in a courteous and respectful manner. Adheres to all company policies and procedures.2.5%6. Maintains time and attendance standards consistent with company policy.2.5%

 

Minimum Qualifications: Education/Experience:

High school diploma or equivalent required. One year of medical, receptionist experience preferred.

Skills/Knowledge:

Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job. Must have strong attention to detail as well as written and verbal communication skills and ability to actively listen. Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English. Ability to spell, proofread and edit written text. Must be able to operate a personal computer and related software application. Must have keyboard proficiency (approximately 70 words/minute). Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues. Ability to communicate and interact professionally with others.

Desired/Preferred Qualifications:

Medical Terminology; AHA BLS card or equivalent

Equipment Use:

Personal computer, typewriter, multi-line telephone, fax machine, and copies

Characteristics:

Effectively participates as a team member with all staff. Committed to the protection of confidential information, records, and/or reports. Communicates effectively in a professional and courteous manner. Possesses functional organization skills. Expresses and demonstrates the interest and ability to work closely with a variety of patients on a one to one basis.  

Hourly Rate:

Starting @ $19.58; based on experience

 

 

Salary : $20