04/26/2022
Medical Scribe
-EMT, CNA, MA, LPN, AUA, Pre-Med Students, Nursing Students
Job Type
Full-time
Full Job Description
Accompanies provider into the patient examination room to document the provider's encounter with the patient.
Collaborates with the provider to document the patient history, physical exam, results of diagnostic testing, and diagnosis and disposition.
PRIMARY 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.List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician
3. Document all procedures performed by the physician, physician extenders, or nurses, on the medical chart.
4. Transcribe consultations or discussions with family and/or the patient's private physician.
5. Complete the patient's charts by transcribing results of any labs, x-rays, or other evaluations.
6. Continuously check the progress of data availability for orders, to ensure the patient's workup is complete so that the provider is able to make treatment decisions regarding that patient.
7. List all proper diagnoses as well as any discharge/follow-up instructions and prescriptions, under guidance of the physician.
8. May occasionally assist with some patient-related duties.
9. Performs other duties as assigned.
EDUCATION
High school diploma or equivalent
EXPERIENCE
Medical Scribing preferred
Medical Terminology preferred
Basic computer and word-processing skills
Other Requirements:
Ability to multi-task efficiently and effectively.
Must be able to act calmly and effectively in a busy or stressful situation
PHYSICAL REQUIREMENTS
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
Frequent keyboard use/data entry.
Occasional bending, stooping, kneeling, squatting, twisting and gripping.
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
Rare climbing.