SUMMARY OF MAJOR FUNCTIONThe scribe works to facilitate patient flow through the Practice and ensure an accurate and complete medical record for each patient. The scribe assists the medical provider by accompanying them during the medical history-taking and exam, recording details of both into the medical record, and coordinating departmental resources regarding tests, orders, radiology and results.The scribe tracks the orders for each patient, records results and notifies provider of results as they arrive.ESSENTIAL FUNCTIONS AND WORK ROLE RESPONSIBILITIESNote: for items 1-3, 5 information is obtained directly from provider – no decision making is done by scribe).
- Record details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factor, medications, and allergies.
- Record details of physical exam, including pertinent positives and negatives, noted abnormalities and patient general condition.
- Submit orders as desired by medical provider or as specified by joint practice protocols.
- If orders are not completed in a timely fashion or if results are incomplete, scribe works with practice managers to troubleshoot for causes and solutions.
- Assist in disposition of patients, clinical visit summary, educational material, prescription and referral appointments.
PHYSICAL ENVIRONMENTMay be exposed to occupational hazards/diseases in physician practices and other patient settings. PHYSICAL CRITERIA/EFFORTWork involves standing and/or walking 90% of the time. Constant hand motion involved with writing, typing, and answering the telephone. Some duties require standing, wide freedom of movement, stooping, bending, lifting, pushing or pulling (<30lbs). Frequent periods of concentration and close attention to detail.SAFETY1. Maintain a safe environment which includes knowing and understanding hospital and departmental policies and procedures.2. Report and directly address identified environmental hazards when appropriate.3. Report and directly address violations of patient safety policy and/or protocol when involved or observed.OCCUPATIONAL RISKSFailure to follow established procedures could result in back injury or strains from lifting, bending (over patients), or pulls and strains from repetitive hand motions. Exposure to blood and/or body fluids.PROBABILITY AND CONSEQUENCES OF ERRORSErrors could result in the communication of patient information and a loss of revenue. .NUMBERS SUPERVISEDNon-supervisory position.MINIMUM REQUIREMENTS FOR THE JOBExcellent communications skills and the ability to deal effectively with the patients and fellow employees. Organizational skills, attention to detail and the ability to work independently to complete job functions.EDUCATIONHigh School Diploma or equivalent. Also, 2 year Medical Assistant degree preferred. EXPERIENCEPrevious experience in a medical office/medical transcription.SPECIAL KNOWLEDGE REQUIRED
- All other duties as assigned.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.
- Working knowledge of medical terminology and accepted abbreviations.
- Recognition of physical exam process and ability to record exam details.
- Legible handwriting and ability to accurately record information.
- Computers proficiency and ability to quickly learn new applications.
- Communication skills and ability to coordinate and cooperate with multiple members of the health care team.
- Organizational skills with focus on tracking patient care and improving patient flow.
- Professional demeanor and recognition of privacy considerations for patient and families.