Clinical Medical Scribe

POSITION SUMMARY

This position records medical details, gathers data, and coordinates tests, orders and results as necessary to ensure an accurate and complete medical record.

Assembles and maintains patients' health information in medical records and charts by assisting medical providers and physicians.

No medical decision making is performed.

CORE FUNCTIONS

1. Accompanies provider during patient examination.

2. Accurately and thoroughly documents pertinent patient information as instructed by the provider. Records details of chief complaint, history of present illness, review of systems, social history, past medical history, family medical history, allergies, medications, problems and diagnoses, history and physical, and any pertinent positive and negative findings.

3. May propose orders in the EHR based on clinical setting.

4. Documents details of procedures and treatments, laboratory test results, radiology test results and assists with documenting radiographic impressions performed by the provider.

5. Assists with verifying all tests (lab, x ray, EKG, etc.) have been completed and the results have been received, reviewed and recorded in the medical record.

6. Selects patient education leaflets from the EHR as instructed by the provider.

7. Assists in preparing paperwork for patient discharge.

8. Maintains confidentiality of all patient information.

9. Works under the direction of Physicians or independent licensed practitioner providing documentation assistance. Internal customers include patients, facility personnel, medical providers and physicians.

External customers may include patient family.

MINIMUM QUALIFICATIONS

High school diploma / GED or equivalent working knowledge.

Employees working at Banner Scottsdale Sports Medicine, second floor must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.

PREFERRED QUALIFICATIONS

Two years of experience in acute care or multi-specialty clinic using electronic medical record software or maintaining medical records.

Additional related education and / or experience preferred.

DATE APPROVED 10 / 15 / 2023

EOE / Female / Minority / Disability / Veterans

Our organization supports a drug-free work environment.

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