Medical Scribe - Cardiology/EP

Major Responsibilities

• Prepares and assembles medical record documentation/chart for physician prior to patient visit.
• Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results.
• Ensures that all elements of documentation are complete and accurate.
• Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications.
• Documents the physician/clinician's communication with the patient using appropriate medical terms and phrasing.
• Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders.
• Documents the correct follow-up instructions and level of service designation based on the physician/clinician's direction.
• Aids in data entry from devices or other sources.
• Completes medical records for each encounter ensuring accurate and timely documentation.
• Under physician/clinician direction, updates patient history and other pertinent health information in the patient record.
• Prepares and sends all documentation for review and approval.
• May perform clinical functions such as prepare and room patient for exam, obtain vital signs and document/update pertinent health information, assist the physician/clinician with non-sterile procedures, schedule appointments and referrals to other facilities or services, and perform other data entry into the EHR.

Licensure, Registration, and/or Certification Required

None Required.

Education Required

High School Graduate.

Experience Required

Typically requires 1 year of experience in medical assisting, medical transcription, emergency medical services, patient service and/or as a health care professional with demonstrated proficiency in medical terminology and technical spelling.

Knowledge, Skills & Abilities Required

• May need successful completion of authorized medical scribe training course within 30 days of hire.
• Knowledge of medical terminology, including basic human anatomy and coding. Demonstrates familiarity with medication names and medical procedures.
• Knowledge of essential elements of documenting a provider-patient encounter, HIPAA compliance, and Centers for Medicare and Medicaid Services requirements.
• Excellent communication and interpersonal skills. Ability to maintain sensitivity and confidentiality for the patient while assisting physician. Ability to develop rapport and maintain positive, professional relationships.
• Requires adherence to all policies and procedures, including but not limited to standards for safety, patient service, attendance, punctuality, and personal appearance.
• Proficient computer skills including: advanced keyboarding, above average typing speed, navigation within a windows operating system, and use of electronic mail with exposure to electronic medical records systems.
• Able to effectively multi-task, with excellent prioritization and organization skills.
• Must have a high attention to detail and accuracy when documenting health information.
• Ability to work effectively in a fast paced and stressful environment.
• Must have ability to travel to various work locations.

Physical Requirements and Working Conditions

• Exposed to a normal medical office environment.
• Position requires travel; therefore may be exposed to severe weather or road conditions.
• Must have functional speech, vision, hearing, and touch with ability to use fine-hand manipulation skills.
• May need to occasionally lift/carry up to 20 lbs.
• May be exposed to the following hazards: mechanical, electrical, chemical, blood and body fluids; therefore must wear protective clothing and equipment as needed.
• Operates all equipment necessary to perform the job.