Job Title: Medical Scribe

Reports To: Office Manager

FLSA Status: Non-exempt

SUMMARY:

Medical Scribes work as personal assistants to physicians, gathering information for patient visits and partnering with physicians to deliver effective patient care. Duties of Medical Scribes include tracking lab and x-ray results and patient evaluation data to healthcare professionals, and recording consultations with healthcare professionals, patients and family members.

Clinical Scribe duties include performing all clerical and information technology functions for a provider in a clinic setting. This includes primary responsibility of the operation of the electronic health records system. A Clinical Scribe is able to anticipate physician needs to facilitate the flow of the clinic.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Ensures accurate and detailed documentation as per the provider(s) instruction

2. Accurately and thoroughly document clinical visits and procedures performed by the provider, including but not limited to:

3. Patient Clinical history and physical exam

4. Procedures and treatments performed by provider

5. Patient education and explanations of risks and benefits.

6. Provider-dictated diagnoses, and instructions for patient or family members for self-care and follow-up

7. Transcribe reports from medical personnel

8. Translate abbreviations into proper for

9. Review reports for completeness

10.Correct errors in transcription, grammar, punctuation and spelling

11. Document medical diagnosis and treatment to EMR

12. Assist Provider in navigating the electronic health record (EHR)

13. Locates information for review (encounters, test results, outside records, etc.)

14. Champions quality initiatives and implements key components into documentation.

15. Troubleshooting basic IT needs (i.e. printer setup, etc.)

11. Notifies provider of any pending items/ system alerts.

12. Actively participates in huddles with care team.

13. Understands clinical scribe scope of practice and maintains awareness of any changes.

14. Attends training on diverse subjects as needed to enhance or maintain performance.

15. Performs other duties as requested.

QUALIFICATIONS:

• At least one year of experience in ambulatory care setting as a Medical Assistant AND knowledge medical terminology.
• Previous experience in medical transcription or other related fields
• Familiarity with transcription devices
• Familiarity with medical terminology
• Strong attention to detail
• Knowledge of EMR clinical and PM
• Bilingual English/Spanish is a must

· Physical examination which indicates that the employee is able to meet the physical requirements of the job including: Lifting, Walking, Stooping, Bending, Twisting.

· Skilled in Microsoft Office, Microsoft Access, data entry, and use of business email.

· Bilingual in English and Spanish is required