Administrative Skills, Anatomy, Billing, Clinical Monitoring, Computer-Based Training (CBT), Customer Support/Service, Detail Oriented, Documentation, Electronic Medical Records, Fax Machines, HIPAA (Health Insurance Portability and Accountability Act), High School Diploma, Legal Documents, Medical Coding, Medical Terminology, Medical Treatment, Medications, Order Processing, Organizational Skills, Patient Care, Patient Charts, Patient Confidentiality, Pediatrics, Record Keeping, Regulations
Winston-Salem, North Carolina
Scribe
Location: Winston Salem, NC and Clemmons, NC
Department: Pediatrics
Full Time: Monday - Monday8am-5pm
*Knowledge of medical terminology Strongly preferred
The Scribe will document information in the electronic medical record at the direction of the physician or advanced practice clinician. The Scribe will document the provider's dictation and/or activities. Any individual serving as a Scribe will have no patient care responsibilities or offer clinical oversight. An individual serving as an in-person Scribe may also serve as a chaperone during sensitive exams after completion of required education.
What We're Looking For:
- Education: High School Diploma or GED, required. 4 Year / Bachelors Degree, preferred.
- Experience: Six months customer service environment experience in the medical field, preferred.
- Additional Skills (required): Working knowledge of medical terminology and technical spelling. Computer aptitude and ability to quickly learn new applications. Communication and organizational skills with focus on tracking patient care and improving patient flow. Ability to record information accurately and promptly. Aptitude to learn or have knowledge of exam, diagnostic and treatment procedures and protocols. Professional demeanor and recognition of privacy considerations for patients and families. Completion of the computer-based learning entitled AMB0742 NHMG Chaperone in the Exam Room if the Scribe will also be serving as a chaperone during sensitive exams.
- Additional Skills (preferred): Specific medical terminology training, knowledge of basic anatomy, coding and HIPAA familiarity, medical, procedural and diagnosis coding experience.
What You'll Do:
- Document patient visits in real time, including history of present illness (HPI), review of systems (ROS), physical exams, procedures, and provider assessments
- Accurately enter information into the EMR while maintaining attention to detail and completeness
- Prepare patient charts prior to visits by reviewing medical history, medications, and previous documentation
- Assist providers during patient encounters by capturing clinical details and facilitating workflow
- Enter and pend orders for labs, imaging, and prescriptions for provider review (as permitted)
- Update patient records with test results, correspondence, and other relevant information
- Ensure all documentation complies with legal, regulatory, and billing requirements
- Maintain strict patient confidentiality in accordance with HIPAA guidelines
- Support administrative tasks such as scanning, faxing, and retrieving records as needed