General Position Summary:
The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter.
Duties and Responsibilities:
1. Accompany the physician upon patient interview and examination.
2. Document accurate, thorough, and timely physician notes (HPI, ROS, PE, A&P, Admission and Discharge summaries) that reflect the full complexity of care provided.
3. Document the physician dictated patient history, past medical and surgical history, family and social histories, medications, and allergies.
a. Maintain awareness of conversations regarding patient care between the provider and other healthcare providers, patients, family, etc. to ensure applicable information is documented
b. Ensure physician notes meet clinical documentation requirements for risk management, billing, etc.
4. Scribes document physical examination findings and procedures as performed by the physician.
5. Scribes document the results of laboratory and radiographic studies as dictated by the physician.
6. Scribes document the correct time of patient care related activities.
7. Assist the provider in applying appropriate billing codes.
8. When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.
9. All orders for patient care must be communicated by the physician and not the Scribe.
10. May participate in patient care solely under the direct supervision, instruction, and direction of the physician.
11. Maintain and demonstrate an understanding of the team approach to patient care and documentation.
12. Complete and present the medical record in collaboration with the supervising physician.
13. Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.
14. Communicate in a professional and respectful manner to the supervising physician and ancillary hospital staff.
Knowledge, Skills, and Abilities:
- The ability to work in a fast pace environment.
- Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
- Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
- Completion of a medical terminology course or one-year medical terminology experience in a clinical setting preferred
- Ability to multi-task and consistently communicate in a professional manner
- Strong communication skills, written and verbal.
- Excellent listening and note-taking skills
- Detail oriented with proven ability to work effectively under conditions requiring accuracy
- Ability to remain calm in a fast paced, at times stressful environment
- Computer proficiency
- Upper level typing/computer skills and proficiency
Work Experience, Education, and Certifications:
- High school graduate or equivalent.
Physical Requirements / Demands:
- Prolonged periods of sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at times.
Essential or Non-Essential Classification:
- This position is designated as a non-essential position and therefore the employee’s presence at work during an emergency or bad weather conditions is not required to meet operational needs.
Statement of Non-Inclusivity:
This job description has been designed to describe the general nature and level of work being performed by the employee within this classification. It is not designed to contain or be interpreted as a comprehensive list of all duties, skills, responsibilities, and qualifications which may be required of or given to any employee assigned to the position. The skills, duties, requirements, and responsibilities outlined in this job description may be changed or added to when deemed appropriate and necessary by the company or the person who is designated to be managerially responsible for this position. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind. Employment with the company is an at-will relationship.
