Scribe

GENERAL SUMMARY OF DUTIES:

Responsible for documenting patient history (including social, family, and past medical), medications, physical examination, review of systems as dictated by the provider in the patient room. Provides information regarding labs, imaging, referrals or any other pertinent information needed by the provider in the exam room. Conveys a positive image of clinic.

SUPERVISION RECEIVED:

Reports to Physician or Office Manager

SUPERVISION EXERCISED:

None

ESSENTIAL FUNCTIONS:

1. Work with/accompany physician at all times
2. Document information in EHR as dictated by provider in exam room
3. Identify and relay information regarding test, procedures, etc. from patient chart
4. Order all labs, imaging, prescriptions, etc. in EHR
5. Retrieve samples
6. Enter diagnoses in EHR
7. Enter charges in MD chart when applicable
8. Complete medical record in EHR for physician to sign
9. Maintain good communication with partnering RMA/CMA
10. Develop strong working relationship with physician
11. Be responsive to provider and patient needs while in exam room
12. Communicate clearly with provider, patient, and co-workers
13. Fulfills organization responsibilities as assigned which may include: respecting/promoting patient rights; responding appropriately to emergency codes; sharing problems relating to patients and/or staff with immediate supervisors quickly.
14. Maintains OSHA/HIPAA Compliance as assigned to include: updating manuals; first responder for employees with exposures/incidents.
15. Other responsibilities or duties as assigned.