POSITION: Medical Scribe DEPARTMENT: Medical Unit STATUS: Full-Time, Non-Exempt
POSITION SUMMARY: Under the direct supervision of the Medical Unit Manager, the Medical Scribe performs all clerical and information technology functions for a physician in a specialty clinic setting, including primary responsibility for the operation of electronic health records and dictation.
Essential Duties and Responsibilities:
1. Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present 2. Greets all patients in a professional and friendly manner. 3. Perform documentation in EHR software for physicians for all patients 4. Handles confidential material while protecting its strict confidentiality under HIPPA guidelines 5. Speak clearly and distinctly using appropriate vocabulary and grammar to obtain and convey information while 6. Transcribe patient orders including laboratory tests, radiology tests, medications, etc 7. Attends and participates in meetings as required. 8. Document any procedures performed by the physician 9. List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. 10. Add Chief Complaints to ECW 11. Other duties as assigned.
Education and Qualifications
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