SCRIBE

JOB SUMMARY:

The Medical Scribe is an individual trained in medical documentation who will assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the provider. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients. The Medical Scribe will follow all local, state and federal guidelines regarding documentation into the electronic health record. The Medical Scribe will be responsible for clearly recording each patient’s symptoms, history, physical exam and documenting the diagnosis. This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front desk staff.

ESSENTIAL FUNCTIONS:

• The primary role of the Medical Scribe is to assist the provider with documentation of patient's medical chart during his or her visit.
• Accompanies the provider into the patient examination room in order to transcribe the patient history and physical examination as given by the patient and provider.
• Documents any procedures performed by the provider or nurses, on the electronic medical chart.
• Is an expert in the use of various templates and documentation techniques available in the EHR (Electronic Health Record) system and use these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
• Transcribes any consultations or discussions with family members and/or the provider.
• Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the medical scribe continuously checks on the progress of this data in order to get the patients workup complete, so the provider is able to make decisions regarding the patient.
• Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE:

• High school graduate or equivalent.
• Medical Scribe Certification and Aptitude Test (MSCAT) certification after 200 hours on the clinic floor, preferred.