Medical Scribe

Job Description

Job Description

Job Summary :

This position creates a dynamic conduit between a tangible document and the patient encounter, clinical exam and provider care.

The role is exclusively clerical; the scribe does not autonomously author any medical information. Scribes function in an auxiliary information pathway to afford the physician or mid-level provider with real time access to substantive documentation without compromising normal routines of facility communication or efficiency.

The position will act as an ambassador on behalf of the company with customers, clients, and vendors in public.

Essential Duties and Responsibilities (not limited to) :

• Accompany physician into the patient exam room in order to transcribe a history and physical exam
• Accurately document the physician’s encounter with the patient and others present
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
• Document any procedures performed by the physician
• Knowledge of electronic medical records
• Records procedures, results, progress notes, and any additional information relevant to the chart
• The scribe does not interject his or her own opinions or impressions, and does not interpret clinical information.
• Documentation to be completed within 24-48 hours of date of service (DOS).
• Maintain professional appearance and conduct at all times
• Adhere to employer policies and procedures
• Attendance / Punctuality Is consistently at work and on time; Ensures work responsibilities are covered when absent
• Other duties as assigned

Skills and / or Qualifications (not limited to) :

• Maintain a valid Iowa driver’s license
• Proof of car insurance
• A typing speed of 50+ WPM
• 1-4 years’ of experience in high-volume interactive clinic or hospital
• Fluency in medical terminology
• Strong verbal and written communication
• Ability to work cooperatively with others in a multi-cultural environment
• Ability to understand and carry out complex oral and written instructions
• Motivation Sets and achieves challenging goals
• Quality Demonstrates accuracy and thoroughness
• Quantity Completes work in a timely manner
• Dependability Follows instructions, responds to management direction; Takes responsibility for own actions; Commits to long hours of work when necessary to reach goals
• Ethics Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically;

Upholds organizational values

• Adaptability Adapts to changes in the work environment
• Diversity Shows respect and sensitivity for cultural differences
• HIPAA guidelines and regulations

Physical Requirements :

• Keen sense of eye sight and hearing;
• Ability to stand or sit for an extended period of time
• Ability to use hand to finger, handle, or feel and talk to hear

Education and / or Experience :

• Required High School diploma or GED
• Employee must be 18 years of age or older
• Mandatory reporting in both children and adult
• Basic Life Support / Cardiopulmonary Resuscitation Certification
15 days ago