Medical Scribe

Description

Medical Scribe Job Description

Summary/Objective: The Medical Scribe, under the direction of the Physician, accurately transcribes patient orders including laboratory tests, radiology studies, and medication orders into the electronic medical record (EMR) in real-time.

Essential Functions: (This list may include but is not limited to the following assigned duties)

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

· Updating patient history, physical exam and other pertinent health information.

· Working with a supervising physician to complete and submit medical records.

· Preparing and assembling medical record documentation for the Physician.

· Learning about the medical process and using a team approach in patient supervision and documentation.

· Evaluates the condition of the examination room to ensure adequate supplies are in stock.

· Taking notes during patients visits and documenting them in the electronic health system.

· Enter the patient's discharge/after visit summary plan and any prescriptions.

· Generate referral letters for physicians, manage and sort medical documents within the electronic medical record system.

· Alert medical provider when chart is incomplete, or if medical record contains errors or inconsistencies documentation in order to reduce errors.

· Dictation/ faxing/phone calls and clerical tasks.

· Accompanies physician into exam room with patient, entering information in electronic medical record regarding patient symptoms and condition as physician interviews patient.

· Transcribes medical decision-making in real time under direction of physician, creating polished patient encounter notes that will also be sent to referring MDs.

· Check schedule to ensure every patient examined has that day's reports in the patient's EHR.

· Incumbent works closely with a team of clinic caregivers, including physicians and mid-level providers to ensure the delivery of high-quality patient care.

· Assure the accuracy of all documentation

· Keep the privacy of all patient information

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to sit; walk; stand, use hands to finger, handle or feel; and reach with hands and arms.

Environmental/Working Conditions:

· Work is performed in a busy office environment and requires both desk and counter work.

· Frequent contact with employees and outside agencies.

· Continual patient contact may involve dealing with angry or frustrated patients.

Travel:

Vineland, Sewell, Mount Laurel, Voorhees. Everyone has been hired to travel. This is NOT a one location position.