What are the responsibilities and job description for the Medical Scribe position at Angel Kids PA?
• Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to: • Patient medical history and physical exam • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants • Patient education and explanations of risks and benefits • Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up • Prepare referral letters as directed by the physician • List all proper admission and discharge diagnosis as well as follow-up care instructions as directed by physician. • Make copies of ALL prescriptions given to Patients • Scan everything you made copies of along with what ever paperwork you are asked to scan • Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned. • Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential. • Excellent written and communication skills REQUIRED. • Strong medical terminology knowledge and understanding REQUIRED. • Must be able to work nights and weekends • Must be able to travel between locations • Typing 30 wpm, MS Office, etc.
