Medical Scribe - Dr. Powell (M-F 8am-5pm)

Position Title

Department

MEDICAL SCRIBE

NURSING

INSTRUCTIONS:

In Section A briefly describe the overall purpose of this position.  Describe the position so that someone who does not know the position will understand it.  In Section B describe the specific tasks or duties.  The percentage of time spent performing the major job responsibilities is used for job evaluation purposes only.  In Section C list the minimum qualifications, type of equipment used (including the frequency), characteristics, environmental factors relating to this position.

SECTION A: OVERALL PURPOSE OF THE POSITION

The Medical Scribe is responsible for accurate, thorough documentation of the clinic visit and/or procedures, as they are being performed by the physician. The primary goal is to increase the efficiency and the productivity of the physician they are working for.

SECTION B: MAJOR JOB RESPONSIBILITIES

*

PERCENTAGE

1.       Accurately and thoroughly document the patient’s medical visits and/or procedures in the electronic medical record (EMR) as instructed by the physician, including but not limited to:

•          Patient medical history and physical exam,
•          Procedures and treatments (diagnostic findings, lab, test results, etc.)
•          Consultations with other providers
•          Emergency Department treatment course/Hospital Admissions information
•          Patient education and explanations of risks and benefits.
•          Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up

*

40

2.       Reviews medical documentation created and checks for errors and inconsistencies.  Discusses findings with physician.  Alerts physician when chart is incomplete.  Demonstrates a professional, non-intrusive interaction with patients.

*

30

3.       Complies with standards of the electronic medical records software, legal and ethical requirements for preparing medical documents and keeping patient information confidential.  Completes assigned tasks in a timely manner to allow physician to sign off and lock clinical note(s) for processing.

*

20

4.       All other miscellaneous responsibilities and duties as assigned.

5

5.       Demonstrates quality work, completes assignments on a timely basis, and makes decisions within limits of authority. Takes initiative in problem solving, maintains confidentiality of patient and company information, and interacts with patients, co-workers, and management in a courteous and respectful manner. Adheres to all company policies and procedures.

2.5

6.       Maintains time and attendance standards consistent with company policy.

2.5

TOTAL:

           100%

SECTION C: OTHER INFORMATION

RESPONSIBLE TO:

DIRECTOR OF NURSING

SUPERVISES:

N/A

MINIMUM QUALIFICATIONS:

Education/Experience:

High school diploma or equivalent required. One year of medical, receptionist experience preferred.

Skills/Knowledge:

·         Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.

·         Strong written and verbal communication skills.

·         Ability to actively listen.

·         Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.

·         Ability to spell, proofread and edit written text.

·         Keyboard proficiency (approximately 70 words/minute).

·         Ability to operate a personal computer and related software applications.

·         Strong attention to detail.

·         Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.

·         Ability to communicate and interact professionally with others.

Desired/Preferred Qualifications:

Medical Terminology

AHA BLS card or equivalent.

Equipment use:

Personal computer, typewriter, multi-line telephone, fax machine, and copies.

Characteristics:

Effectively participates as a team member with all staff. Committed to the protection of confidential information, records, and/or reports. Communicates effectively in a professional and courteous manner, Possesses functional organization skills. Expresses and demonstrates the interest and ability to work closely with a variety of patients on a one to one basis.