Medical Scribe
Location: Orange Park, FL
Onsite - Monday - Friday 8am - 5pm
Contract to Hire
Pay Rate: $20/hour - $22/hour
Position Overview:
The Medical Scribe works alongside healthcare providers to capture patient visit details as care is delivered. This position helps maintain complete, timely, and accurate medical records by entering information into the electronic medical record system, organizing clinical details, and supporting the provider’s documentation process. By managing charting tasks during and around patient visits, this role helps improve office flow, documentation consistency, and the overall patient care experience.
Key Responsibilities
Clinical Documentation:
- Record visit details during patient encounters, including the reason for visit, relevant history, exam observations, provider assessment, and care plan as directed.
- Input provider-directed notes and updates into the electronic medical record with attention to accuracy and clarity.
- Add chart information such as test results, imaging summaries, medication details, and other visit-related information when instructed by the provider.
- Review documentation for completeness and alignment with internal guidelines, provider preferences, and applicable documentation standards.
Patient Visit and Office Flow Support:
- Review upcoming patient charts before visits to identify prior notes, current medications, recent results, and other relevant background information.
- Help providers locate information in the medical record during appointments or between patient visits.
- Monitor assigned documentation tasks, pending orders, and outstanding results according to provider direction and office workflow.
Team Communication:
- Coordinate with providers, nursing team members, and office staff to support an organized patient care process.
- Confirm unclear documentation details with the provider before finalizing chart entries.
- Demonstrate professionalism, discretion, and respect for patient privacy in all communications and interactions.
Privacy and Compliance:
- Follow HIPAA requirements and company privacy practices when accessing, entering, or discussing patient information.
- Use secure documentation practices and maintain confidentiality of protected health information at all times.
Additional Duties:
- Provide support for related medical office tasks as assigned based on daily operational needs.
- Participate in assigned training and remain familiar with updated office procedures, documentation expectations, and workflow changes.
- Complete other job-related responsibilities as requested.
Qualifications:
- Minimum of 2 years of experience as a Medical Scribe in a clinical or healthcare setting.
- Proficient in documenting patient encounters accurately and efficiently in real time.
- Strong multitasking skills with the ability to manage multiple priorities in a fast-paced environment.
- Exceptional attention to detail and commitment to maintaining accurate medical records.
- Experience working with Electronic Medical Record (EMR) systems; experience with Athena is preferred but not required.
- Strong understanding of medical terminology, clinical workflows, and healthcare documentation standards.
- Excellent written and verbal communication skills.
- Ability to maintain patient confidentiality and comply with HIPAA regulations.
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