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Scribe

SUMMARY

Performs all clerical and information technology functions for a physician in a specialty clinic setting, including primary responsibility for the operation of electronic health records and electronic dictation systems. Primary goal is to increase the efficiency and productivity of the physician. This position will have no direct involvement in patient care.

QUALIFICATIONS/EDUCATION

  • High School Diploma or equivalent
  • Bi-lingual English/Spanish preferred; must be able to read, write and speak English.
  • Minimum of a two-year degree, or two years or more experience in a medical office.
  • Medical coding training or certification are preferred.
  • Basic computer knowledge, MS Word and MS Excel.
  • Customer Service Skills.

CERTIFICATIONS/LICENSES

  • N/A

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:  Patient medical history and physical exam, Procedures and treatments performed by healthcare professionals, including nurses and physician assistants, Patient education and explanations of risks and benefits, Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
  • Prepare referral letters or request as directed by the physician, via dictation or summary of the medical record. 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. Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
  • Spot 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. 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. Alert physician when chart is incomplete.
  • Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
  • Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
  • Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
  • 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.
  • Collect, organize and catalog data for Physician Quality Reporting System and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.
  • Attend trainings on diverse subjects such as information technology, legal and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures.
  • Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
  • Able to accompany the physician upon patient interview and examination.
  • Able to document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
  • Able to document physical examination findings and procedures as performed by the physician.
  • Able to document the results of laboratory and radiographic studies as dictated by the physician.
  • Able to document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
  • The Scribe will make “chart rounds” to review with physicians as to patient status, delays, and any other care-related issues.

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Allowed Type(s): .pdf, .doc, .docx
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