Scribe

GENERAL SUMMARY OF DUTIES: United Digestive’s (UD) Scribe is a dedicated team member who provides comprehensive patient care and documentation support in our gastroenterology clinic. This role requires working alongside a physician or physician extender to meet all needs of their assigned provider while maintaining excellence in patient care. The position involves real-time documentation during patient encounters, clinical support activities, and administrative responsibilities.
REPORTS TO: Practice Manager
RESPONSIBILITIES:
Duties include but are not limited to:
Documentation and Scribe Services
Accompany the physician upon patient interview and examination
Document the physician dictated patient history, physical examination, family, social, and past medical history, procedures, lab results, dictated radiographic impressions made by the physician and any other information pertaining to the patient's visit
Review all documentation completed and make any necessary amendments
Complete diagnostic coding and procedure coding accurately
Patient Care and Clinical Support
Verify patient information by interviewing patient, recording medical history, and confirming purpose of visit
Prepare patients for examination by performing preliminary physical tests including taking blood pres-sure, weight, and temperature
Report patient history summary to healthcare providers
Counsel patients by transmitting physician's orders and questions about procedures
Prepare charts for upcoming appointments
Administrative and Compliance Responsibilities
Secure patient information and maintain patient confidence by completing and safeguarding medical records
Keep patient information confidential in compliance with HIPAA regulations
Maintain a safe, secure, and healthy work environment by establishing and following standards and pro-cedures
Comply with legal regulations and practice policies
Keep supplies ready by inventorying stock, placing orders, and verifying receipt
Performs any other duties and/or special projects as assigned
EDUCATION, SKILLS, & EXPERIENCE:
Required:
High school diploma or equivalent
Minimum 1-2 years of experience in healthcare setting, with general clinical competence in acute patient care, customer service experience in a healthcare setting
Ability to work independently with minimal supervision, multitask effectively during patient encounters, accurately document physician dictation and patient communication
Preferred:
Medical scribe, documentation, gastroenterology and/or specialty practice experience
Medical assistant certification (CMA, RMA, or CCMA) and/or completion of medical assistant program from accredited institution strongly preferred
Medical scribe training or certification and/or healthcare-related training or coursework
Aspiring medical student or demonstrated interest in healthcare; plans to pursue medical school are a plus.
CORE SKILLS AT UNITED DIGESTIVE:
The Scribe must have or be able to:
Must be computer literate and able to operate various healthcare systems and multiple Microsoft Office applications.
The ability to communicate with patients, visitors, co-workers, and physicians with courtesy and respect.
Communicate clearly with patients and coworkers through the telephone, email, and in-person.
Plan, prioritize, and complete multiple tasks as delegated.
Displays a professional outgoing warm and helpful attitude.
PHYSICAL/MENTAL/ENVIRONMENTAL DEMANDS:
Requires sitting and standing associated with a normal office environment. Ability to move between patient rooms for extended periods. Manual dexterity for real-time documentation and computer data entry. Visual acuity for reading charts, observing procedures, and computer screens. Hearing acuity for accurately documenting physician dictation and patient communication. Travel required as business needs dictate.
DRUG FREE WORKPLACE:
United Digestive is a drug-free workplace. All offers of employment are contingent upon passing a pre-employment drug screening.
EQUAL OPPORTUNITY EMPLOYER:
United Digestive is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, gender, color, or national origin in its employment practices.