Medical Scribe

POSITION DESCRIPTION:

The Medical Scribe will accompany the providers and accurately document events and decision-making in a manner that results in appropriate medical charting. The Medical Scribe will be responsible for assisting healthcare providers by entering information into the electronic medical record (EMR), gathering necessary patient history information prior to, during, and after the patient visits, and providing other general note taking and clinically focused administrative assistance.

The Medical Scribe works to facilitate patient flow and ensure an accurate and complete medical record for each patient.

DUTIES AND RESPONSIBILITIES:

• Accompany provider into patient examination room to 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.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
• Document patient orders including lab tests, radiology tests and medications.
• Document any procedures performed by provider.
• Document and enter referrals for the patient as dictated by the provider.
• Patient education and explanations of risks and benefits.
• 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.
• Responsible for identifying mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors and ensures that all addenda must be signed off by a physician.
• Responsible for complying 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.\Responsible to proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
• Concentrate on the needs of the provider throughout entire shift.
• Understand and observe legal concepts (e.g. HIPAA, confidentiality).
• Other duties as assigned.

REQUIREMENTS:

• Computer proficiency, including keyboarding, Microsoft Office and Electronic Medical Record.
• Organization skills with focus on tracking patient care and improving patient flow.
• LPN or Medical Assistant preferred.
• Ability to multi-task efficiently and effectively.
• Knowledge of medical terminology and medical environment.
• Proficient in typing, spelling, punctuation and grammar.

TRAINING AND EXPERIENCE:

• High School diploma, GED or equivalent training and experience.
• Minimum of 2 years experience in a medical office.
• Prior experience with Electronic Medical Records.
• Medical assistant or medical scribe diploma from an accredited vocational institution, or a community college course in medical assisting or a Healthcare student -physician, nursing, physician assistant, healthcare administration, etc.

SPECIAL REQUIREMENTS:

• Medical Scribing experience preferred.
• EMR experience required; experience with EClinical (ECW) preferred.
• Reliable transportation.

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong written and verbal communication.
• Ability to work and communicate effectively.
• Keyboard and typing proficiency.
• Ability to demonstrate knowledge of medical terminology and human anatomy.
• Ability to observe and to draft a narrative account of events accurately and cogently, and grammatically.
• Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.
• Knowledge of medical procedures, medical laws and ethics.
• Strong attention to detail.
• Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical.
• Must possess organizational, problem-solving, and communication skills to articulate medical requirements to staff members, patients, families/care givers, and medical and non-medical staff in a professional and courteous way
• Knowledge of office administrative procedures, EMR usage, and general medical office procedures.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Ability to Commute:

• Oviedo, FL 32765 (Required)

Ability to Relocate:

• Oviedo, FL 32765: Relocate before starting work (Required)

Work Location: In person