What are the responsibilities and job description for the Med Scribe - Cardiology position at Aurora Health Care?
Major Responsibilities :
- In accordance with policy, prepares and assembles medical record documentation / chart for physician prior to patient visit. Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results. Ensures that all elements of documentation are complete and accurate.
- Enters the patient room with the physician / clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications. Documents the physician / clinician's communication with the patient using appropriate medical terms and phrasing.
- Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and / or referrals and the associated diagnosis to be connected with those orders. Documents the correct follow-up instructions and level of service designation based on the physician / clinician's direction. Assists in data entry from devices or other sources.
- Completes medical records for each encounter ensuring accurate and timely documentation. Under physician / clinician direction, updates patient history and other pertinent health information in the patient record. Prepares and sends all documentation for review and approval.
- With proven competency, may perform clinical functions such as preparing and rooming the patient for exam, obtaining vital signs and documenting / updating pertinent health information, assisting the physician / clinician with non-sterile procedures, scheduling appointments and referrals to other facilities or services, and performing other data entry into the EHR.
Licensure, Registration, and / or Certification Required :
Education Required :
Experience Required :
Knowledge, Skills & Abilities Required :
Physical Requirements and Working Conditions :
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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