The successful applicant will be responsible for documenting accurate and detailed information of patient visits. The ideal candidate will provide the highest quality customer service to patients, adhere to practice protocols and processes, and effectively manage the volume of work without allowing quality to be compromised. A summary of a Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job since you will be hard to replace.
Prepare charts for physicians prior to each session, including reviewing previous notes for patient, creating office note for upcoming visits and populate it with relevant data from previous visits and history. Accompanies physician during consultation and examination
Transcribes details of the interview and physical exam per physical instruction utilizing medical terminology and documentation guidelines within the EMR
Completes all necessary documentation of the patient encounter in the medical chart including entering orders as dictated by the physician
Scans and files lab reports/test results and charts via electronic medical record alerting the physician as laboratory or radiology results become available
Follows up on lab reports and tracks any missing or delayed studies
Prepares discharge instructions for the physician to review with the patient
Scribes may not act independently but documents the physician's or licensed independent practitioner's dictation and/or activities
0-1 years of experience must possess strong organizational skills and be detail oriented
High school diploma
College graduate preferred
Language Skills – The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at 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. Handwriting must be clear and legible.
Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
Mathematical Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
Reasoning Ability – Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.
Physical Demands – While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus
Must have the ability to interact effectively and efficiently with patients and coworkers
Must have a high level of professionalism and maturity
Must be able to work effectively and efficiently with minimal supervision
Computer proficiency with the ability to quickly learn new applications
Previous Electronic Medical records experience preferred