Medical Scribe – Workers’ Compensation / Industrial Clinic
Job Responsibilities
The Medical Scribe is responsible for providing accurate, timely, and comprehensive clinical documentation support to physicians and advanced practice providers in a fast-paced Workers’ Compensation and industrial medicine setting. The Medical Scribe must have a strong understanding of medical terminology, anatomy, clinical procedures, and Workers’ Compensation documentation requirements.
Primary Responsibilities
- Accompany the provider during patient evaluations and accurately document the encounter in the electronic medical record (EMR).
- Prepare clear, complete, and medically appropriate histories of present illness (HPI), including mechanism of injury, date of injury, affected body parts, current symptoms, treatment history, and response to prior treatment.
- Document relevant past medical history, surgical history, medications, allergies, prior injuries, prior Workers’ Compensation claims, and other pertinent clinical information.
- Accurately document physical examination findings as dictated or performed by the provider.
- Document the provider’s diagnoses, assessment, treatment recommendations, work restrictions, and plan of care.
- Assist with documentation of diagnostic studies, including MRI, CT, X-ray, EMG/NCV, and other testing, ensuring that findings are accurately incorporated into the medical record.
- Document treatment recommendations such as physical therapy, acupuncture, chiropractic treatment, medications, diagnostic testing, injections, interventional pain procedures, specialist referrals, and surgical consultations when directed by the provider.
- Assist with preparation of Workers’ Compensation reports and documentation, including initial evaluations, follow-up reports, progress reports, Primary Treating Physician (PTP) reports, and other required medical-legal documentation.
- Ensure documentation clearly identifies the accepted or evaluated date(s) of injury and body parts addressed during the encounter.
- Document the patient's current work status, temporary work restrictions, modified-duty recommendations, or return-to-work status as directed by the provider.
- Assist providers with documentation necessary to support Requests for Authorization (RFAs) and ensure the medical record contains the clinical rationale supporting recommended treatment.
- Review available medical records, diagnostic reports, prior treatment documentation, AME/PQME/QME reports, and other relevant records in preparation for the patient encounter.
- Identify missing medical records, diagnostic studies, authorizations, or other documentation needed for the provider's evaluation and communicate deficiencies to the appropriate staff.
- Maintain accurate documentation of treatment progress, including changes in pain, function, range of motion, activities of daily living, response to treatment, and ongoing limitations.
- Ensure that documentation accurately reflects the provider’s medical opinions and treatment recommendations without independently diagnosing, interpreting findings, or making treatment decisions.
- Assist the provider with completing documentation promptly following each patient encounter and ensure reports are ready for review and signature within established clinic timelines.
- Maintain accurate patient records while complying with HIPAA, patient confidentiality requirements, Workers’ Compensation regulations, and clinic policies.
- Communicate professionally with physicians, physician assistants, nurse practitioners, medical assistants, front-office staff, authorization personnel, transcription staff, and other members of the clinical team.
- Assist with tracking outstanding diagnostic studies, referrals, treatment authorizations, and follow-up requirements when assigned.
- Travel between clinic locations as required to provide direct scribe support to assigned providers.
- Maintain familiarity with commonly used orthopedic, pain-management, neurological, and musculoskeletal terminology and procedures encountered in an industrial medicine practice.
- Perform other documentation, administrative, and clinical-support duties as assigned by the physician, practice administrator, or management.
Documentation Standards
The Medical Scribe is expected to produce documentation that is accurate, organized, professional, and consistent with the provider’s findings and medical opinions. Documentation must clearly establish the history of the industrial injury, current complaints, objective findings, diagnoses, treatment provided, treatment recommendations, work status, and follow-up plan.
The Medical Scribe must never independently alter a diagnosis, treatment recommendation, work restriction, causation determination, or other medical opinion without direction and approval from the treating provider.
Job Type: Full-time
Pay: $21.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Employee discount
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Medical Specialty:
- Pain Medicine
- Primary Care
Work Location: On the road
