Medical Scribe

Departments

  • North Star Recovery

Work Hours

  • 80 Hours
  • Full Time

Categories

  • Administrative / Clerical

Job Summary

The medical scribe’s primary responsibility is to work within the electronic health record and dictation systems to ensure patient records are accurate and complete. The scribe must also anticipate the provider’s needs to ensure a flow within the clinic. The scribe must be modest, discreet, and respectful while completing their duties to ensure minimal distraction from patient care.

Qualifications

  • Education:
    • High school diploma or equivalent required
  • Training and experience:
    • Must be proficient in in typing with minimal errors, and use the appropriate spelling, grammar and punctuation.
    • Must have excellent listening skills, and be able to summarize complex medical information, in a clear and concise fashion.

Essential Functions

  • Utilize the electronic health record and dictation systems to ensure patient records are accurate and complete.
  • Must anticipate the medical provider’s needs to ensure smooth flow within the clinic or department.
  • Must be modest, discreet and respectful while completing scribe duties to ensure minimal distraction from patient care.
  • Must have good organizational abilities, attention to detail, and self-motivation to ensure that patient records are completed in an accurate and timely fashion.
  • Must remain flexible, and adapt to the department’s everchanging environment.
  • Collaborate with the medical provider to document medical visits, or procedures as they are being performed. Documentation must include: a thorough history and physical exam; procedures performed by any medical professional; education provided to the patient including the risks and benefits discussed; diagnosis and subsequent prescriptions; any referrals or directions provided by the medical provider.
  • Perform clerical functions as directed by the provider including faxing, dictation, or phone calls.
  • Review the electronic health record to identify mistakes, or inconsistencies in documentation. Ensure any changes, or corrections made are signed and dated by the appropriate medical provider.
  • Collaborate with analysts within Health Information Management to ensure medical records comply with all FRHS and ethical standards.
  • Collect data as directed for quality reporting purposes.
  • Remain knowledgeable in topics such as HIPAA, Federal and State compliance, and billing and coding.

Status

  • 8:00am-5:00pm or 10:00am-8:00pm
  • Days vary
  • weekend rotation