What are the responsibilities and job description for the Medical Scribe position at Trinity Employment Specialists?
Medical Scribe
Monday-Friday | Tulsa, OK
$17-$21/hour DOE
Job Summary:
The Scribe is a support role and is responsible for playing a vital role in supporting healthcare providers by accurately documenting patient encounters in real-time. The incumbent will report to the Office Manager (or similar role) and will work closely with providers to facilitate 5-star service of care to our patients.
Scribe Responsibilities:
- -Accurately document patient encounters, including medical histories, physical examinations, procedures, and treatment plans, in real-time
- -Ensure thorough and organized documentation in the electronic health record system
- -Assist healthcare providers with documentation, allowing them to focus on patient care
- -Anticipate the needs of providers during examinations, procedures, and consultations
- -Facilitate communication between healthcare providers, nursing staff, and other members of the healthcare team
- -Collaborate with providers to clarify and complete medical documentation
- -Enter relevant patient data into the EHR system accurately and efficiently
- -Maintain patient confidentiality and adhere to privacy regulations
- -Participate in quality assurance activities to ensure the accuracy and completeness of medical documentation
- -Collaborate with providers to address any discrepancies or missing information
- -Additional duties as assigned
Scribe Requirements/Skills:
- -Bachelor’s degree in a healthcare related field or relevant experience
- -Previous experience as a Medical Scribe is preferred
- -Detail oriented with a commitment to accuracy and thorough documentation
- -Working knowledge with Google Suite (Drive, Docs, Sheets, Slides) and Microsoft Office (Word, Excel, PowerPoint) for real-time collaboration
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* Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.
* Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.
* Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
* Consult classification manuals to locate information about disease processes.
* Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.