Summary:
A Medical Scribe is responsible for assisting healthcare providers by documenting patient encounters in real-time during medical examinations, ensuring accurate and thorough documentation in the patient’s medical record. The primary goal is to increase the efficiency of healthcare professionals by allowing them to focus on patient care while the scribe handles documentation and other administrative tasks.
Essential Duties and Responsibilities:
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Percentage
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Duty or Responsibility
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60%
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- Document Patient Encounters:
- Accurately document patient history, physical exams, diagnoses, treatments, procedures, and other relevant clinical information in the electronic health record (EHR) system.
- Record the healthcare provider’s verbal instructions and interactions with the patient.
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10%
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- Assist in Patient Flow:
- Coordinate with medical staff to ensure timely and efficient flow of patients in the clinic or hospital.
- Assist with preparation for patient exams, including obtaining relevant medical records or lab results.
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10%
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- Support Providers:
- Help healthcare providers with entering orders, prescriptions, and follow-up care instructions.
- Ensure that all medical documentation meets legal, regulatory, and organizational standards.
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5%
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- Maintain Confidentiality:
- Adhere to HIPAA and patient confidentiality laws while handling sensitive medical information.
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5%
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- Prepare for Medical Procedures:
- Document procedures, treatments, and other interventions accurately as per provider instructions.
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5%
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- Communication:
- Communicate with medical staff, patients, and other departments as needed to facilitate smooth patient care delivery.
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5%
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- Other Duties as assigned by supervisor
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Units Billed Minimum Requirement:Â None
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Special Attributes:Â
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- Proficient in typing and documentation skills with attention to detail.
- Familiarity with EHR software and other healthcare technologies.
- Ability to work under pressure in a fast-paced environment.
- Strong communication skills (both written and verbal).Â
- Professional demeanor and ability to work with diverse medical teams
Supervisory Responsibilities:Â None
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Qualification Requirements:Â
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- Previous experience as a medical scribe, medical assistant, or in a healthcare setting is preferred, but not required.
- Knowledge of medical terminology, anatomy, and physiology is highly beneficial.
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Education and/or Experience:
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- BA/BS Degree or equivalent required.
- positions may require a degree or certification in healthcare-related fields (e.g., Health Information Technology, Medical Assisting, etc.) or to be in process of an advanced degree (MD, DO, PA, NP)
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Language Skills: Ability to read, analyze, and interpret human service periodicals, professional journals, technical procedures, or government regulations. Ability to write reports, business correspondence, effective treatment notes and related documents. Ability to effectively present information and respond to questions from groups of managers, clients, customers and/or the public.
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Mathematical Skills: Ability to calculate figures and amounts such as percentages, mean, mode and median; ability to interpret bar graphs.
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Certificates, License, Registration: Certification in Medical Scribing is preferred but not required Â
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Physical Demands: While performing the duties of this job, the employee is regularly required to talk or hear. The employee is regularly required to stand, walk, sit, use hand to finger, handle or feel objects, tools or controls; and reach with hands and arms. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
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Work Environment: Generally pleasant office conditions. May on occasion drive to locations outside county for trainings or meetings while driving may be exposed to various weather conditions.
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OSHA Category: Duties involve no exposure to blood, body fluids, or tissues, but employment may require performing unplanned Category I procedures. All category I employees are offered the opportunity to receive the Engerix Hepatitis B vaccination series.
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Other: This description is intended to describe the essential job functions, the general supplement functions and the essential requirement for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirement of the position. Other functions may be assigned, and management retains the right to add or change the duties at any time.
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