MEDICAL SCRIBE

JOB SUMMARY: The Medical Scribe assists their assigned physician by performing all clerical and information technology functions for the physician in a clinic setting. The primary goal of the medical scribe is to increase the efficiency and the productivity of the practitioner (physician and/or mid-level provider). Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. The Scribe must be adaptable and versatile and maintain good attendance. The Scribe must be able to anticipate the practitioner (physician and/or mid-level provider) needs to facilitate the flow of clinic.

ESSENTIAL FUNCTIONS:

1. Participates in Care team huddles- initiates pre-visit planning workflow to ensure Physician Care Plan completion prior to visit whenever possible
2. Maintains confidentiality at all times.
3. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to: 1) Patient medical history and physical exam; 2) Patient screening and assessments such as PHQ9, SDOH; 3) Procedures and treatments performed by healthcare professionals, including nurses and physician assistants; 4) Patient education and explanations of risks and benefits; 5) Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up; 6) Prepare referral letters as directed by the physician
4. Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribe 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. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
5. Monitors for 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.
6. Ensures 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. 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.
7. Monitors physicians open encounters, PAQ and assists provider in addressing to maintain compliance.
8. Medical Scribes collect, organize and catalog data for physician quality reporting and other quality improvement efforts and records in EHR and format for submission.
9. Assists in developing and maintaining systems to track patient follow up and compliance.
10. 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. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
11. Participates in Care coordination, Care team quality improvement activities including care team performance on required clinical, operational and financial measures.
12. Any other duties deemed necessary by immediate supervising physician/Nurse Manager.

The above reflects the general duties considered necessary to describe the principal functions of the job and shall not be considered as a detailed description of all work that may be assigned by the immediate supervisor, and/or health care provider of that may be inherent in the position as it relates to each specialty group (i.e., Family Medicine, Internal Medicine, Pediatrics, OB/GYN, etc.)

CUSTOMER SATISFACTION REQUIREMENTS: Must provide the very best customer satisfaction to patients, visitors, and co-worker at all time in a professional and courteous manner. Provide assistance in resolving customers’ problems. Coordinate efforts and interfaces with other departments to resolve problems. Actively protects customer confidentiality. Actively keeps environment clean and safe with a professional and welcoming image. Always treats customers as welcome guests and provides a warm and sincere greeting. Consistently presents a professional appearance in dress and grooming by adherence to dress code policy. Effectively and regularly demonstrates the values of the organization. Effectively involves customers in decisions that affect them. Follow through in a timely manner of commitments made to customers. Take ownership of your attitude toward Service Excellence

PERFORMANCE STANDARDS: Performance will be evaluated by the Supervising Physician or designee annually wherein an overall satisfactory rating is considered as a minimum acceptable level of performance.

PRIVACY RULE COMPLIANCE REQUIREMENTS:

1. Adheres to Health Insurance Portability and Accountability Act (HIPAA Privacy Rule) policies and procedures.
2. Must successfully complete Privacy Rule compliance training annually or as revisions are made to the policies and procedures.
3. Must comply with Privacy Rule guidelines by learning to protect FPHC patient’s medical privacy.
4. Must comply with Privacy Rule guidelines by appropriately maintaining our patient information in compliance with national standards.

5. Must comply with Privacy Rule guidelines by providing appropriate security of FPHC patient records

HEALTH AND SAFETY REQUIREMENTS: The health and safety requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1. Must adhere to safety regulations, personnel policies and procedures.
2. Safety and Hazard Communication training update is required annually.
3. Knowledgeable of OSHA and CLIA requirements to assure compliance.
4. Maintain yearly health maintenance records by obtaining TB skin testing and completion of the hepatitis series.

PROTECTED HEALTH INFORMATION (PHI) ACCESS: RESTRICTED- For purposes of HIPAA Compliance there are 4 workforce categories, which define the level of access to PHI that is granted to the incumbent. This position is classified under PRIMARY PROVIDERS and therefore granted RESTRICTED access- to be defined according to workforce member’s specific job duties. Use and disclosure must be in accordance with applicable privacy policies and procedures.