Medical Scribe

Job Description

Job Description

The duties of a Scribe are to document the dictated patient history, physical examination, family, social, and past medical histories as well as document procedures, lab results, dictated radiographic impressions and any other information pertaining to the patient's encounter in the Emergency Department or other clinical medical setting. Scribes are not patient care providers, nor are they part of the hospital staff; they are solely employed by Florida Physician Group and as such are the physician's representative and employee.

Outline of Essential Functions :

Scribes are assigned to work with one physician / allied health provider ("provider") per shift.

Scribes accompany the provider upon patient interview and examination.

Scribes document the dictated patient history, including history of present illness, review of systems, past medical and surgical histories, family and social histories, medications and allergies.

Scribes document physical examination findings and procedures as performed by the provider.

Scribes document the results of laboratory and radiographic studies as dictated by the provider.

The provider and the Scribe will make "chart rounds" to review patient status, delays, and any other care-related issues.

All orders for patient care must be communicated by the provider and not the Scribe.

Scribes must document their signature (name and title) along with a date and time stamp within the medical record. As per Joint Commission, the role and signature of the Scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff.

When the physician concludes the patient's encounter, the provider will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The Physician is ultimately responsible for documentation of the patient's encounter.

Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible provider or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc.

Additional Responsibilities :

Maintain and demonstrate an understanding of the team approach to patient care and documentation.

Complete and present the medical record in collaboration with the supervising provider.

Participate in ongoing educational opportunities as offered by HSA or Florida Physician Group.

Attend scheduled Florida Physician Group staff meetings.

Communicate in a professional and respectful manner to the supervising provider, OP practice staff ancillary hospital staff, and Florida Physician Group leadership.

Knowledge / Skills / Abilities :

Demonstrate the knowledge and skills necessary to document patient care as dictated by a provider in a clear manner, following all local, state, and federal guidelines for documentation.

Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.

Demonstrate organizational ability to maintain and coordinate both electronic and paper records related to patient care for multiple patients at a time

Cooperates fully with all risk management activities and investigations

Observes and complies with Hospital and Physician Practice Codes of Safe Practice, safety policies and emergency procedures.

Minimum Position Qualifications :

High school graduate

Minimum one-year and 5 shifts per week availability to work

Excellent computer knowledge and typing abilities

Completion of a medical terminology course or one year of medical terminology experience in a clinical setting

Punctuality and preparedness for all shifts and work-related activities

Professional appearance is required. Must comply with dress code policies to be outlined upon hire.

Ability to check and respond to all correspondence, including email, phone calls or text messages in a timely manner.

Preferred Position Qualifications :

Healthcare bound student - physician, nursing, physician assistant, healthcare administration, etc.

College level education including health or medical related courses

Advanced knowledge of medical terminology

Fluency in a foreign language, preferably Spanish and willing to obtain certification as a translator

Willing to provide two or more years of availability to work

Environmental Conditions :

Ambulatory-care settings including but not limited to emergency departments, outpatient clinics and inpatient hospital settings.

Exposure to patients of various acuity levels ranging from low acuity to critically ill.

Physical Requirements :

Ability to stand for extended periods of time, with shift lengths of up to 10 hours.

Normal vision (or corrected vision) and hearing

Ability to handwrite large amounts of dictated information during your shift (in the event the EMR system has gone down)