Supervisor: Clinic Administrator
Position: Non Exempt
Supervisory Responsibilities: None
General Summary of Duties: Performing all clerical and information technology functions for a physician in a clinic setting. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job.
- Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
- Patient medical history and physical exam.
- Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
- 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
- Prepare referral letters as directed by the physician
- Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. You may be asked to generate electronic orders for prescriptions, DME, diagnostic exams, surgeries, physical therapy, and occupational therapy.
- Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
- Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
- Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
Education: High School Diploma and one year of college, preferably in the area of Pre-Health Studies.
Experience: Medical Scribe/Dictation service, Pre Med Student, or Medical Assistant Graduate
- Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
- Organizational skills with focus on tracking patient care and improving patient flow
- Professional demeanor and recognition of privacy considerations for patients and families
- Communication skills and the ability to coordinate and cooperate with multiple members of the health care team
- To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments.
- Ability to record exam details
- Computer proficiency and ability to quickly learn new applications
- Ability to record information quickly and accurately
- Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.
- The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.
Equipment Operated: Computer Desktop, Laptop, or Tablet.
Mental/Physical Requirements: While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.
Job Type: Full-time
Salary: $14.28 to $22.87 /hour