Job Description

Medical Scribe

Job Summary: A Medical Scribe is responsible for recording a Physician's interactions with patients and assisting with clerical duties related to medical documentation.

Primary Job Responsibilities:

• Accompany the physician upon patient interview and examination.
• Document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
• Document physical examination findings and procedures as performed by the physician.
• Document the results of laboratory and radiographic studies as dictated by the physician.
• Document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
• Maintain and demonstrate an understanding of the team approach to patient care and documentation.
• Complete and present the medical record in collaboration with the supervising physician.
• Communicate in a professional and respectful manner to the supervising physician, and ancillary hospital staff.
• Performs other duties as assigned.

Requirements

Education: High school diploma or general equivalency diploma (GED)

Experience: Minimum one year of Medical Scribe experience in a medical office setting preferred, basic medical terminology is a plus.

Performance Requirements:

Knowledge:

Knowledge of medical terminology and office procedures.

Knowledge of grammar, spelling, and punctuation to type from draft copy and review and edit reports and correspondence.

Knowledge of basic arithmetic to make calculations, balance and reconcile figures, and make changes accurately.

Skills:

Skill in operating office equipment.

Skill in organizational matters including time management, prioritization, and multitasking.

Skill in writing and communicating effectively.

Skill in problem-solving.

Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.

Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.

Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations

Abilities:

Ability to type using word-processing software. Able to learn/use other computer programs including Microsoft® Excel, including Word, and Excel, e-mail, and Internet

Ability to use standard office equipment, including but not limited to a computer, phone, fax machine.

Ability to read, understand, and follow oral and written instructions.

Ability to sort and file materials correctly using alphabetic or numeric systems.

Ability to communicate clearly and concisely.

Ability to establish and maintain effective working relationships with patients, physicians and other clinical staff, and the public.

Equipment Operated: Office machinery including computers, fax, dictating machine, calculator, and photocopier.

Work Environment: Medical office, well lighted, well ventilated. Work may be stressful due to a busy office. Involves frequent contact with doctors, staff, and patients.

Physical Requirements: Must possess the physical and mental abilities to perform the tasks normally associated with a Medical Scribe such as manual dexterity to operate office machines including computer and calculator; stooping, bending, reaching, standing for extended periods of time or sitting for extended periods of time. Ability to handle occasional occupational stress due to workload.

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