Facility: 55 Whitcher Street

Job Summary: The Certified Medical Assistant Scribe (CMA Scribe) functions under the direction of the physician, nurse supervisor, or practice/office manager. Recognizes patient's needs and symptoms in advance. Provides care for the patient under the physician's direction. Includes preparing patient for exams, assisting during treatments, coordinating tests and follow-up care, and recording care in the medical record. Assists with explaining patient instructions to the patient/family. Demonstrates competency and skills to serve patients of all ages including neonate, infant, child, adolescent, adult, and geriatric populations. The CMA Scribe observes the provider during patient encounters and performs documentation on the provider's behalf, via the patient's electronic medical record (EMR). All documentation is reviewed and/or edited by the provider. It is signed with an attestation by the provider that the scribed chart accurately reflects all work performed by the provider. Performs other duties as necessary. Core Responsibilities and Essential Functions: Evidence Based Practice and Research A. Promotes evidence-based practice, regarding safe, quality patient care. Participates in activities such as value analysis as part of the decision-making process in evaluating patient care products. B. Upholds all health care system/organizational policies and procedures and clinical competencies put forth by this job description and professional association including legal, regulatory and accreditation requirements and standards ensuring by way of example, such goals as TJC Patient Safety Goals and Wellstar Health Systems safety absolutes C. Participates in data collection poses relevant clinical questions to advanced evidence- based practice. Consults appropriate experts and uses appropriate resources and evidence to address practice questions. Clinical Documentation/Scribing A. Chart in real-time as the physician assesses and examines the patient B. Document the history, physical exam, assessment and plan, procedures, treatment, and physician consultations C. Record dictated notes and Pend orders for physician to review and Sign D. Locate and obtain past medical histories, previous charts, past results, and studies E. Check on the progress of labs, imaging studies, and other patient data F. Retrieve and display current and past EKGs and imaging films (e.g., x-rays) for the physician to review and document interpretation G. Understand basic ICD-10 documentation requirements H. Comply with all national and local PHI laws Teamwork and Collaboration A. Coordinates the delivery and documentation of safe quality patient care that promotes the professional care delivery model. This includes but is not limited to diverse and inclusive interdisciplinary communication methods (huddles), completion of timely documentation and promotion of a respectful, inclusive clinical environment. B. Demonstrates teamwork and collaboration by practicing in a manner that is fiscally responsible and promotes the recruitment and retention of all healthcare team members Patient Liaison A. Provides relationship-based patient centered care that is consistent with population specific characteristics (e.g., age, gender, disease, etc.) in a manner that adapts service delivery to reflect an understanding of cultural diversity B. Always partners with the patient and significant others and/or family (as appropriate); keeping the patient at ease in the physicians office, and making the patients goals the focus of the plan of care C. Practices using current clinical practice standards Professional Development and Initiative A. Completes all initial and ongoing professional competency assessment, required mandatory education, and population specific education B. May be asked to serve as a preceptor for onboarding Medical Assistants/students and is an exemplary role model for all staff or students for all disciplines to ensure that there is a current and future qualified workforce, modeling professionalism and creating a healthy work environment Resources and Support A. Proactively plans for the care of patients across the care continuum B. Participates in the development of protocols and procedures when called upon or through self- initiation in collaboration with care managers and other members of the health care team to achieve best practice outcomes C. Supports efficient and effective use of human and material resources Required Minimum Education: High school diploma and/or equivalent Required and Graduate from an accredited medical assistant program Preferred Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated.

• Cert Medical Assistant
• Basic Life Support or BLS - Instructor

Additional License(s) and Certification(s): Current certification from one of the following medical assisting credentialing bodies: AAMA (CMA), AMT (RMA), NHA (CCMA) or NCCT (NCMA). Required Must have a current BLS card from the American Heart Association, prior to hire date. Required Required Minimum Experience: Work experience in a physician practice setting and medical scribe experience Preferred and Specific experience in practice specialty Required Required Minimum Skills: Must be organized and attentive to detail. Must be able to work quickly and efficiently to assure patient comfort and satisfaction. Excellent verbal and written communication skills. Strong computer skills technological savvy. A typing speed of 50 WPM.