What are the responsibilities and job description for the Clinical Scribe position at VITA PHYSICIANS P.C.?
Medical Scribe
Job Summary:
A medical scribe is a trained professional who accompanies a physician or other healthcare provider during patient encounters to accurately and efficiently document the visit in real-time in the electronic medical record (EMR). The scribe's role is to enhance physician productivity and patient experience by relieving the provider of administrative documentation duties.
- Accompany the provider into the examination room during patient visits
- Accurately and thoroughly document the patient's history, physical examination findings, procedures, instructions, and plan of care in the EMR as dictated by the provider
- Ensure proper formatting, grammar, and medical terminology in documentation
- Navigate the EMR system proficiently to locate previous records, enter orders, document charges, etc.
- Prioritize tasks and manage the documentation workflow to keep up with the provider
- Comply with all privacy and confidentiality regulations (HIPAA)
- Maintain a professional demeanor and strong communication skills with patients and staff
- Clarify any unclear information with the provider as needed
- High school diploma or equivalent
- Completion of a comprehensive medical scribe training program
- Strong knowledge of medical terminology, anatomy, and common procedures
- Excellent listening, multitasking, and typing/computer skills
- Ability to work well under pressure in a fast-paced environment
- Attention to detail and commitment to accuracy
- Good interpersonal and customer service skills
This covers the core responsibilities of documenting patient encounters accurately in the EMR while working alongside healthcare providers. The job requires strong medical knowledge, documentation skills, and the ability to work efficiently in clinical settings
As a medical scribe, there are several important rules and guidelines that must be followed:
- Scribes must maintain strict patient confidentiality and privacy in accordance with HIPAA regulations. This includes not discussing patient information outside of the clinical setting.
Scribes cannot give medical advice, opinions, or recommendations to patients. Their role is solely documentation.
- Scribes must objectively document exactly what the provider says without editorializing or altering the content.
- Scribes should always maintain a professional appearance and demeanor when in the clinical environment.
- They must exhibit strong communication skills and emotional intelligence when interacting with patients and staff.
- The documentation must be precise, complete, and accurate, reflecting the provider's statements and the encounter details.
- Scribes should clarify any unclear information with the provider rather than making assumptions.
- Scribes cannot improperly access or modify portions of the EMR outside their role and the current encounter.
- All documentation must be attributable to the scribe's unique login credentials.
Adhering to these rules around privacy, neutrality, professionalism, accuracy, and EMR integrity can help medical scribes perform their duties properly while upholding ethical standards and regulatory requirements in healthcare settings.
- Focus on capturing the most critical elements first - chief complaint, history of present illness, physical exam findings, assessment, and plan.
- Fill in additional details like the review of systems and past medical history when time allows.
- Develop a personalized shorthand system using abbreviations and phrases.
- Utilize EMR templates and smart phrases when available for common documentation.
- Pay close attention to the provider's statements to avoid missing key details.
- Ask clarifying questions if something is unclear rather than guessing.
- Become familiar with each provider's documentation style and preferences.
- Predict upcoming components based on the typical encounter flow.
- Type while the provider is speaking and examining the patient.
- Toggle between different EMR sections as needed.
- Immediately after the visit, review and fill in any missing documentation.
