Scribe

SUMMARY

This position requires the incumbent to provide clerical and information technology support for a physician within the practice. This includes primary responsibility of the operation of the electronic health records and electronic dictation system.

Job Duties & Essential Functions

• Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
  • Patient medical history and physical exam
  • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
  • Patient education and explanations of risks and benefits.
  • Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
• Identify mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician.
• 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. Alert physician when chart is incomplete.
• 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.
• Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding.
• Quickly assimilate new knowledge into processes and procedures.
• Proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.
• Add additional duties as assigned.

Required Education & Qualifications

• High School Diploma/GED
• Proficient in typing, spelling, punctuation, grammar, and oral communication.
• Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.
• Excellent English composition skills required to generate professional, polished writing at a high rate of production.
• Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports.
• Must be able to learn and use all functions of electronic medical record software and transcription software.
• Able to type words and numbers quickly and accurately.
• Comply with HIPAA confidentiality standards when accessing or communicating patient information.
• Good judgment, organizational ability, initiative, attention to detail.
• Proficient in Microsoft Office Word and Excel.

Preferred Qualifications

• 1 year of experience as Scribe or Medical Assistant (must have graduated from an MA program) or in a medical office.
• Scribe certification will be considered in lieu of experience or college coursework as related to position.
• Bachelor’s degree.
• Ability to type 50-60 words per minute.
• Bilingual.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to communicate with patients, staff and medical providers. The employee must be able to exchange accurate information in these situations. This position is active and requires the employee to constantly move about in the office to assist patients, staff and medical providers. Any additional physical demands will be outlined and provided by management.