| Position Overview : In this role, the Scribe's primary goal is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient.
Essential Duties and Responsibilities: Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to: - Patient medical history and physical exam,
- Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
- 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
- Prepare referral letters as directed by the physician
- Ability to perform administrative functions to include: dictation/faxing/phone calls and other clerical task.
- Ability to research contact information for referring physicians, coordinate and prepare documentation relevant to patient-centered care.
- Provide consistent medical documentation and check that all information obtain by physician is correct in order to reduce errors.
- All addenda must be signed off by a physician.
- Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.
- Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential with a key understanding of HIPAA compliance.
- Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.
Key Skills: - Language Skills - The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.
- Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
- Mathematical Skills - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
- Reasoning Ability - Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.
- Computer Skills:
- To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software.
- Must accurately enter data into a database, search for information, send and receive email and attachments.
- Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents.
- Must use Microsoft Excel to prepare flowcharts and organize data.
- Must use the internet to access schedules, research information, etc.
Preferred Qualifications: High School diploma Computer competency, including understanding of, and ability to work with, Microsoft Windows based pulmonary function software programs
Excellent verbal and written communication skills
Qualified candidates must be able to effectively communicate with all levels of the organization. All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer - M/F/Veteran/Disability |
