Applicants for this position must have knowledge of medical terminology and experience with medical scribing, transcription or other real-time notetaking.
Medical Scribes are individuals trained in medical documentation and use of electronic medical records who assist physicians in the outpatient clinic. The primary function of a Medical Scribe is to increase the efficiency and productivity of the physician. Scribes allow the physician to focus on the patient. A summary of duties for a Medical Scribe include performing all clerical and information technology functions for a physician in a clinical setting. This includes entering data into the electronic health record and/or electronic dictation system as instructed by the physician. 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 skills, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. The Medical Scribe should be reliable, versatile, and accountable. They should have the ability to type at least 60 wpm with 0 errors.
1. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician including patient medical history and physical exam, procedures, orders, prescriptions, patient instructions, referrals and letters.
2. Typing skills of at least 60 wpm with 0 errors, dictation/faxing/phone calls and clerical tasks. Medical Scribes also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient's care, and with all copies of pertinent reports or tests attached. Scribes may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
3. Medical Scribes also spot mistakes or inconsistencies in medical documentation, and check to correct the information in order to reduce errors. All notes and orders recorded by the scribe must be signed off by the physician, including addenda. Medical Scribes 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, and alert the physician if the chart is incomplete. Medical Scribes must 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.
4. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.
5. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding or as required by the organization. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.
6. Medical Scribes are part of the patient visit. Therefore they must follow the guidelines and requirements of employment as indicated by the physician, clinical staff, management, Employee Health, and the organization.
7. Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.
8. Other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
· Language Skills – The ability to write routine reports and correspondence, proficient in typing, 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.
· Medical Terminology - 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.
· Computer Skills – To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.
Desired: Strong preference for candidates who have completed medical scribe/transcription/terminology schooling and/or have min 1 year experience in medical scribing or medical transcription.
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. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.