Ambulatory Care, Clinical Assessment, Computer Skills, Data Collection, Discharge Plans, Documentation, High School Diploma, Hospital, Medical Record System, Medical Records, Medical Terminology, Medical Treatment, Medical Writing, Patient Care, Time Management
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Job Type
Full-time
Description
Summary/Objective: A Medical Scribe is essentially a personal assistant to the provider; performing documentation in the EHR, gathering information for the patient's visit, and partnering with the provider to deliver efficient patient care.
Essential Functions
- Accompanies the physician into the patient room
- Document the history of the patient's chief complaint
- Document the Review-of-Systems (ROS) and physical examination
- Enter vital signs and keep track of lab vaues
- Look up pertinent past medical records
- Keep track of and enter the results of imaging studies
- Type progress notes and enter the patient's discharge plan
- Interprets and records information from physician accurately and in a timely manner while utilizing medical terminology and completing records per documentation guidelines/procedures within the EHR while facilitating smooth work flow with physician.
- Submits orders into computer as directed by physician.
- Performs any other duties as directed by physician or supervisor.\
Hospital based
Requirements
Required Education and Experience: High school diploma or GED. 1 year experience working in an ambulatory care setting, must possess a working knowledge of medical terminology, abbreviations, and demonstrates computer proficiency.
Additional Eligibility Qualifications: Current BLS certification or to be completed within three months of employment. Must pass basic typing test.