Job Description
Job Description
Medical Scribe
Monday-Friday Milton, FL Temp-hire
$17-$21 / hour DOE
Job Summary :
The Scribe is a support role and is responsible for playing a vital role in supporting healthcare providers by accurately documenting patient encounters in real-time.
The incumbent will report to the Office Manager (or similar role) and will work closely with providers to facilitate 5-star service of care to our patients.
Responsibilities :
- Accurately document patient encounters, including medical histories, physical examinations, procedures, and treatment plans, in real-time
- Ensure thorough and organized documentation in the electronic health record system
- Assist healthcare providers with documentation, allowing them to focus on patient care
- Anticipate the needs of providers during examinations, procedures, and consultations
- Facilitate communication between healthcare providers, nursing staff, and other members of the healthcare team
- Collaborate with providers to clarify and complete medical documentation
- Enter relevant patient data into the EHR system accurately and efficiently
- Maintain patient confidentiality and adhere to privacy regulations
- Participate in quality assurance activities to ensure the accuracy and completeness of medical documentation
- Collaborate with providers to address any discrepancies or missing information
- Additional duties as assigned
Requirements / Skills :
- Bachelor’s degree in a healthcare related field or relevant experience
- Previous experience as a Medical Scribe is preferred
- Detail oriented with a commitment to accuracy and thorough documentation
- Working knowledge with Google Suite (Drive, Docs, Sheets, Slides) and Microsoft Office (Word, Excel, PowerPoint) for real-timecollaboration
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At least one year experience
Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries.
Transcribe dictated reports and translate abbreviations into fully understandable form. Edit as necessary and return reports in either printed or electronic form for review and signature, or correction.
- Return dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.
- Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
- Identify mistakes in reports and check with doctors to obtain the correct information.
- Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
- Transcribe dictation for a variety of medical reports, such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, or discharge summaries.
- Distinguish between homonyms and recognize inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
- Set up and maintain medical files and databases, including records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.
- Translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.
- Perform data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
- Take dictation using shorthand, a stenotype machine, or headsets and transcribing machines.
- Perform a variety of clerical and office tasks, such as handling incoming and outgoing mail, completing and submitting insurance claims, typing, filing, or operating office machines.
- Decide which information should be included or excluded in reports.
- Receive and screen telephone calls and visitors.
- Receive patients, schedule appointments, and maintain patient records.
- Answer inquiries concerning the progress of medical cases, within the limits of confidentiality laws.