JOB SUMMARY
Under the direct oversight and presence of the Provider (Physician and/or Licensed Independent Provider), the Certified Assistant/Medical Scribe provides annotation, under their own login profile, into the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations/ guidelines for documentation. The Certified Medical Assistant/Medical Scribe will be responsible for clearly recording each patient’s symptoms, history, physical exam and documenting the diagnosis. Work with the provider to provide patient care by performing tasks under the supervision of the physician. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.
PRIMARY JOB RESPONSIBILITIES
- Accurately and thoroughly document medical visits and procedures as they are being performed by the provider, including but not limited to:
- Patient chief complaint, reason for visit, medical history, review of systems and physical exam,
- Procedures and treatments performed by providers.
- Patient orders, including for example laboratory tests, imaging tests
- Patient education and explanations of risks and benefits.
- Provider-dictated diagnoses, codes, prescriptions and instructions for patient or family members for self-care and follow-up.
- Look up past medical records, tracking and entering results at the direction of the provider.
- Review the record and verify that the documentation requirements have been met for the designated codes assigned by the provider. Proofread and edit all the provider’s medical documents for accuracy, spelling, punctuation, and grammar. Identify mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors, ensuring that all addenda are signed off by provider. Ensure that all clinical data, lab or other test results, the interpretation of the results by the provider are recorded accurately in the medical record, alerting provider when chart is incomplete.
- Comply with documentation compliance 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.
- Prepare referral letters as directed by the provider, via dictation or summary of the medical record. Ensure that letters are mailed or faxed on a daily basis to all providers involved in a patient’s care, and with all copies of pertinent reports or tests attached. Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
- Collect, organize and catalog data for provider quality reporting system and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.
DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES
Work with the provider to provide patient care by performing tasks under the supervision of the physician such as:
- Assisting with patient procedures
- Taking patient medical histories
- Instructing patients about medications, tests and procedures
- Performing vision and diagnostic tests
- Coordinating patient scheduling
- Supervising and training other allied ophthalmic personnel
- Uses interpersonal skills effectively to build and maintain a mutually respectful working relationship with providers and all members of the healthcare team.
- Works and communicates in a positive and cooperative manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel, patients and their families when providing information and services, seeking assistance and clarification, and resolving problems.
- Contributes to team efforts.
- Carries out assignments responsibly.
- Participates in a positive and cooperative manner during staff meetings.
- Handles difficult and sensitive situations tactfully.
- Responds well to supervision.
- Communicates appropriate information to co-workers.
- Assists with training of new employees as needed.
JOB SPECIFICATIONS
EDUCATION
- High school diploma or equivalent required.
- Certificate of completion of Medical Assistant program. Must be credentialed through AAMA (American Association of Medical Assistants) as a CMA, through AMT (American Medical Technologists) as an RMA, through NHA (National Health Career Association) as a CCMA, or through NCCT (National Center for Competency Testing) as a NCMA, or through AAH (American Allied Health) as an RMA. Recent graduates may be considered prior to credentialing but must obtain within 90 days of hire.
- Current Basic Life Support certification required upon hire.
EXPERIENCE
- Experience working with medical providers and allied health professionals.
- Knowledge of medical terminology preferred.
- Familiarity with requirements for accuracy and speed of typing of multiple medical reports required.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Language Skills: 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.
- 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.
- Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
- Reasoning Ability: 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.
- Computer Skills: 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. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.
- Other Skills and Abilities: Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information
ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS
These physical requirements are not exhaustive and additional job related physical requirements may be added on an as needed basis. Corrective devices may be used to meet physical requirements.
- Sedentary Work: Frequently required to stand, kneel and crouch. On a daily basis may be required to move about, sit, climb stairs and bend. Able to stand for extended periods of time, and able to physically operate the necessary computer and office equipment. Is frequently required to lift and carry up to 20 lbs. May be required to push/pull/carry items between 20-100 lbs.
- Vision: Requires the ability to perceive the nature of objects by the eye. Near acuity: Clarity of vision at 20 inches or less. Midrange Acuity: Clarity of vision at distances of more than 20 inches and less than 20 feet.
- Motor Coordination: While performing the duties of the job, it is required to regularly perform functions that include using hand and finger movement, handle or feel objects, be able to use tools or equipment that requires reaching with hands and arms.
- Must be able to travel independently throughout the hospital; access patients/families including areas confined by space and/or equipment.
- Speaking/Hearing: Ability to give and receive information through speaking and listening.
ESSENTIAL TECHNICAL ABILITIES
- Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
- Manual dexterity required for a high degree of proficiency in high speed keyboarding, minimum of forty words per minute.
ESSENTIAL MENTAL ABILITIES
- Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
- Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
- Able to work in a stressful environment due to time constraints and handle difficult and sensitive situations tactfully and confidentially at all times. Able to follow instructions to learn work routines and problem solve. Able to concentrate and maintain accuracy with frequent interruptions.
ESSENTIAL SENSORY REQUIREMENTS
- Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
- Able to hear for work-related purposes.
- Excellent listening skills and the ability to correspond through written and verbal communications. Visual and auditory intensity required for transcribing for extended periods of time.
INTERPERSONAL SKILLS
- Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
- Required to remain calm when adversity is encountered.
- Open, honest, and tactful communication skills.
- Ability to work as a team member in all activities.
- Positive, cooperative and motivated attitude.
