Scribe

As an unlicensed member of the team, this position is responsible for documenting the physician’s or licensed independent practitioner’s dictation and/or activities into the medical record.

Qualifications

• High School Diploma or equivalent.
• State criminal background check and Federal (if applicable), as required for regulated areas.

Responsibilities

• Record the physician’s or licensed independent practitioner’s dictation into the medical record, including history of present illness, past medical history, review of systems, medications, social history, family history, allergies, or other elements of the patient chart.
• Accompany the physician or licensed independent practitioner in the patient examination area to transcribe a history and physical examination as given by the patient and physician or licensed independent practitioner.
• Document in the medical chart any procedures performed by the physician, licensed independent practitioner, or nurses.
• Transcribe any consultations or discussions with family and/or the patient’s private physician or the on-call physician.
• Gather laboratory results, radiology results, medical records, and other data for review by the physician or licensed independent practitioner. Data should not be entered into the EMR or chart until reviewed and approved by the physician or licensed independent practitioner.
• Continuously check on the progress of data to complete the patient’s workup so the physician or licensed independent practitioner can make treatment decisions.
• Make and answer calls for the physician or licensed independent practitioner, but may not take medical data over the phone or provide verbal orders.
• Communicate waits and delays as directed by the RN, physician, or licensed independent practitioner.
• Print the physician’s or licensed independent practitioner’s process at their direction.
• May not provide verbal orders, relay verbal orders, give medical advice, communicate medical information, or care plans directly with the patient, family, or friends.

Skills

• Working knowledge of medical terminology and accepted abbreviations.
• Computer proficiency and ability to quickly learn new applications.
• Strong communication skills and ability to coordinate with multiple members of the healthcare team.
• Organizational skills with a focus on tracking patient care and improving patient flow.
• Professional demeanor and recognition of privacy considerations for patients and families.
• Typing speed of 50 wpm preferred.
• Position is subject to core competencies and quality assurance monitoring.

Physical Requirements

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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Schedule

Scheduled Weekly Hours: 16