Medical Scribe

Under the direct supervision of the Medical Unit Manager, the Medical Scribe performs all clerical and information technology functions for a physician in a specialty clinic setting, including primary responsibility for the operation of electronic health records and dictation.

Essential Duties and Responsibilities:

• Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present
• Greets all patients in a professional and friendly manner.
• Perform documentation in EHR software for physicians for all patients
• Handles confidential material while protecting its strict confidentiality under HIPPA guidelines
• Speak clearly and distinctly using appropriate vocabulary and grammar to obtain and convey information while
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc
• Attends and participates in meetings as required.
• Document any procedures performed by the physician
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
• Add Chief Complaints to ECW
• Other duties as assigned.

Education and Qualifications:

• High School Diploma or equivalent
• Ability to work with people of diverse cultural, educational, social, and economic backgrounds.
• Detailed knowledge of medical terminology and the ability to distinguish different exams and medical diagnoses
• Ability to work independently and a self-starter with minimal supervision
• Excellent oral and written communication skills • Excellent organizational skills
• Computer proficiency
• They must have exceptional organizational skills with focus on tracking patient care and improving patient flow.
• Experience utilizing an Electronic Medical Records (EMR) system is highly desirable
• Bilingual preferred
• Obtain CPR within two weeks of hire