Medical Scribe (Urgent Care Dept. M-Th 5:30 pm - 8:00 pm and 9:00 am- 1:00 pm) (Healthcare)

Base Salary: $ 21.00- $31.50/hour
JOB SUMMARY
Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the physician. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state and federal guidelines for documentation into the electronic health record system. The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front office staff.

JOB DUTIES AND RESPONSIBILITIES

The primary role of the Medical Scribe is to assist the clinician with documentation of each patient's medical chart during his or her visit.
Accompanies the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
Documents any procedures performed by the clinician or nurses, on the electronic medical chart.
Is an expert in the use of various templates and documentation techniques available in the EHR system, and use these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
Transcribes any consultations or discussions with family members and/or the clinician.
Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient's workup complete so that the clinician is able to make his or her decisions regarding that patient.
Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
Other duties as assigned.

Optional Trainable Skills

A Scribe can be trained to perform vitals, room patients, handle Patient Portal tasks for your assigned provider, chart abstraction, and assisting in other departments such as HIS, or Radiology.

KNOWLEDGE, SKILLS, AND ABILITIES

Recognition of physical exam process and ability to record exam details quickly and accurately.
Must be able to listen to complex medical information and summarize in a clear, complete and concise fashion.
Strong attention to detail.
Computer proficiency in Windows environment and ability to quickly learn new applications.
Ability to communicate effectively in the English language in person, by phone and in writing.
Typing 45 WPM or greater.

EDUCATION & EXPERIENCE

High school diploma or equivalent.
One year experience in healthcare field or minimum 2 years of college education.

PREFERRED Qualifications

2-4 years of college education desired with Medical Terminology, Anatomy and Physiology coursework/degree.
Experience working in an outpatient clinic or doctor's office.
Medical Transcriptionist experience.
Typing 60 WPM or greater.