Medical Scribe RN

Description:

Southeastern Cardiology Associates, Southeastern Gastroenterology Associates, and SBD Medical Solutions strive to deliver the best care possible through a team approach. From check-in to check-out, each employee participates in delivering the highest quality of care and attention in the Southeast. Our commitment to our patient is that we will treat them like family.

We are compassionate and considerate. We are passionate about advancements in technology and patient care. We are educators and good listeners. We believe that qualified specialty care is not hard to find. However, we think that embedding a world-class group of specialists within a team that is committed to treating the patient and their loved ones is what truly sets us apart. Our job is not done when the condition is diagnosed and treated appropriately. We consider the mission accomplished when we have treated the problem and our team has communicated effectively with the patient and their loved ones. Above all, we are here to serve our patients and their families. Our team of specialized physicians, mid-levels, nurses, technicians, and staff are committed to providing the highest level of service – this team approach truly sets us apart.

Medical Scribe Responsibilities

• Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician, including but not limited to: patient medical history & physical exam, patient education and explanation of risks and benefits, physician dictated diagnoses, prescriptions and instructions for patient or family members for self-care or follow-up, preparation of documents as directed by the physician
• Identifies errors in medical documentation and corrects the information. All addenda must be signed off by a physician. Ensures that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.
• Complies 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 according to AMA, CMS, ICD-10, & HIPPA guidelines.

Nursing Duties

• Provides nursing care to patients and accepts delegation from assigned supervisor and/or provider in order to meet the needs of the patient/family
• Collects data and information to assist the clinical team and/or the provider in patient assessment and care planning which includes but is not limited to:

• Communicating through telephone encounters
• Reviewing documents
• Reviewing hospital/clinical records
• Prioritizing patient assignments

• Delivers care in accordance with the treatment, as well as in accordance with policies and procedures of the office
• Possesses excellent communication (written & verbal) skills and participates in teamwork
• Effectively and respectfully communicates with other departments of the office
• Demonstrates cardiac related knowledge and appropriately applies knowledge to patient care
• Demonstrate computer & electronic medical record systems skills
• Exhibit an ability to adapt to unpredictable situations within the work setting
• Independently completes assignments in a timely manner

Requirements:

Education and Qualifications

• Holds/maintains active RN license in Georgia
• Holds/maintains active BLS certification
Holds/maintains active ACLS certification

Corporate Culture Expectations

Demonstrates the office Corporate Culture at all times with colleagues, providers, outside offices/vendors, patients and their family members. Consistently portrays a positive attitude; excels in individual role while creating a culture of teamwork and cooperation; puts the patient/family first and regularly seeks opportunities for self-improvement as well as operational improvement.?

Core Competencies

Approachability, Compassion, Customer Focus, Dealing with Ambiguity, Decision Quality, Ethics & Values, Integrity & Trust, Motivating Others, Peer Relationships, Drive for Results, Listening?

Functional Competencies

Communication, Listening, Organizing, Priority, Technical Learning, Time Management, Understanding Others