Scribe (31175)

General Summary

Responsible for transcribing medical progress notes for physicians and other healthcare professionals into medical reports, correspondence, and other administrative material, which typically become part of patients’ permanent files.

Ssential Job Responsibilities

• Transcribe notes for physicians during a patient visit and place orders for lab/imaging/medications as requested by the physician.
• E&M and CPT coding under the direction of the physician.
• Assist the physician in procedures as needed.
• Perform other duties as assigned such as checking in patients, scheduling appointments, answering the telephone, scanning patient documents, and handling the physician’s voicemail.
• Other clerical duties as assigned by a manager.
• Review physicians' telephone encounters and documents.
• Pre-chart notes and acquire missing records required for the visit.
• Scribes are not authorized to interact with patients without direct instructions from the provider.
• Under no circumstances is the scribe to make any medical decisions, place orders, or prescribe medication without direct supervision from the provider.
  

Qualifications

Education:

Bachelor’s degree is recommended but not always required. On-the-job training is often available in a medical practice supervised by an experienced scribe.

Experience

Minimum one year of medical transcription experience, preferably in a medical practice environment.

Knowledge

Performance Requirements:

• Medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments.
• How to translate medical jargon and abbreviations into their expanded forms using the physician’s guidance.
• Medical record protocols and legal and ethical requirements related to keeping patient information confidential.
  
  

Skills

• Spotting mistakes or inconsistencies in a medical report and correcting the information.
• Following medical record style standards.
• Navigating an EMR and Microsoft software.