Medical Scribe

SUMMARY

The Medical Scribe is responsible for the operation of the electronic health records and electronic dictation system. This position requires for the Medical Scribe to be physically present at the Nursing Homes where the physician provides 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. The Medical Scribe must have the ability to quickly assimilate new knowledge into processes and procedures. The Medical Scribe will proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:

oPatient medical history and physical exam

oProcedures and treatments performed by healthcare professionals, including nurses and physician assistants.

oPatient education and explanations of risks and benefits.

oPhysician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up

• Dictation/faxing/phone calls and clerical tasks.
• Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.
• 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.
• Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
• 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.
• Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.

MINIMUM QUALIFICATIONS

• Associate’s Degree or license in nursing or allied health fields, preferred
• Knowledge of medical terminology and human anatomy a plus
• Skilled in operating various medical record software and hardware, word-processing, and database software programs

EEO / M/ F/ D/ V/ Drug-Free Workplace: