Medical Scribe

General Summary

A Medical Scribe is a paraprofessional who acts as a personal assistant to a Physician or Doctor and collects information from patients in real-time during their visits. In addition, he/she will function within a secondary role as EHR superuser and trainer, and MA onboarding trainer. Also assists providers with examination and treatment of patients. Prepare treatment rooms, position instruments and equipment, as needed per chief complaint. Operate medical equipment, provide injections and/or treatments.

DUTIES & RESPONSIBILITIES

• Taking notes during patient visits and documenting them in the electronic health records system
• Learning about the medical process and using a team approach in patient supervision and documentation
• Working with a supervising Physician or Doctor to complete and submit medical records
• Communicating with patients and supervising Physicians professionally
• Completing all administrative tasks efficiently and helping the Physician take tests and give out medication
• Establish reason for visit and document chief complaint, per the patient's description, on progress note in patient chart.
• Take patient vital signs, including but not limited to blood pressure, pulse rate, height and weight, etc.
• Instruct patient on preparation for physician's examination.
• Assist patients in need of help, i.e. elderly, handicap, pediatric, etc.
• Apply dressings and give injections, when assigned.
• Maintain supply and inventory for exam room, in accordance with clinic and OSHA requirements.
• Review patient charts for completeness, as well as order processing, for referrals, lab, x-ray, etc.
• Assist with medication refills.
• Provide cross-coverage for team members
• Inform scheduled patients of any delays in care
• Log patient information in respective data banks, i.e., State Immunization Tracking System.
• Performs miscellaneous job-related duties as assigned.

EDUCATION & EXPERIENCE

• Prior experience in a healthcare setting
• Nationally Registered Certified Medical Assistant, required
• 10 years or more experience as a pediatric NRCMA, required
• Fluent in Spanish, verbal and written, required
• Knowledge of medical terminology
• Skilled in operating various medical record software and word-processing software programs
• Experience as a team lead for medical assistants

KNOWLEDGE, SKILLS, ABILITIES AND OTHER CHARACTERISTICS

• Knowledge of medical terminology
• Understanding of medical note content and medical billing and coding
• Ability to expertly document patient care and transcribe patient appointments
• Advanced computer skills
• Confidentiality and privacy of the patients
• Strong organization, multitasking and time management skills
• Ability to handle high-pressure situations effectively
• Excellent written and verbal communication skills
• Good bedside manner and interpersonal skills
• Must be able to work both with a team and independently
• Ability to problem solve
• Extensive knowledge and ability to train others in the EHR system
• Knowledge and management of OSHA and CLIA-waived testing
• Training new medical assistants in the role of clinical medical assistant