Med Assistant Scribe

Major Responsibilities:

• Prepares and rooms the patient for exam by obtaining vital signs and gathering/documenting/updating pertinent health information (i.e. chief complaint, allergies, and/or medications).
• Performs laboratory procedures (i.e. strep test, wound culture, specimen collection, etc.) using principles of aseptic technique and standard precautions/infection control guidelines.
• Assists the physician/advance practice provider (APP) with procedures and surgeries such as pelvic exams, allergy scratch testing, EMG, cautery, colposcopy, etc.
• Administers routine medications, under physician/APP orders, which may include but are not limited to immunizations, antibiotics, vitamins and topical agents.
• Provides basic patient instructions on the performance of routine tasks or skills. Follows through with necessary procedure or test requests, pre-approved care algorithms, new appointment times and referrals to other facilities or services. Refers questions to registered nurses and physicians/providers per scope of practice guidelines and relays information back to patient as directed.
• Communicates with physicians and other members of the health care team to ensure smooth clinic flow and makes adjustments as necessary. Effectively communicates accurate and timely information with the patient.
• 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.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

• Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required.

Education Required:

• Completion of an accredited or approved program in Medical Assistant.

Experience Required:

• Typically requires 1 year of experience in medical assisting, medical transcription, emergency medical services, patient service and/or as a health care professional with demonstrated proficiency in medical terminology and technical spelling.

Knowledge, Skills & Abilities Required:

• Successful completion of Aurora authorized medical scribe training course within 30 days of hire.
• Ability to perform routine and complex technical skills, within the Medical Assistant scope of practice after demonstrated competency.
• Knowledge of medical terminology, including basic human anatomy and coding. Demonstrates familiarity with medication names and medical procedures.
• Knowledge of essential elements of documenting a provider-patient encounter, HIPAA compliance, and Centers for Medicare and Medicaid Services requirements.
• Excellent communication and interpersonal skills. Ability to maintain sensitivity and confidentiality for the patient while assisting physician. Ability to develop rapport and maintain positive, professional relationships.
• Requires adherence to all policies and procedures, including but not limited to standards for safety, patient service, attendance, punctuality, and personal appearance.
• Proficient computer skills including: advanced keyboarding, above average typing speed, navigation within a windows operating system, and use of electronic mail with exposure to electronic medical records systems.
• Must have a high attention to detail and accuracy when documenting health information.
• Ability to work effectively in a fast paced and stressful environment.

Physical Requirements and Working Conditions:

• Position requires travel; therefore may be exposed to severe weather or road conditions.
• Must sit, stand, walk, lift, squat, bend, twist, crawl, kneel, climb, and reach above shoulders throughout the workday.
• Must be able to:
• lift up to 50 lbs from floor to waist.
• lift up to 20 lbs over the head.
• carry up to 40 lbs a reasonable distance.
• push/pull with 30 lbs of force.
• perform a sliding transfer of 150 lbs with a second person present.
• Must have functional speech, vision, hearing, and touch with ability to use fine-hand manipulation skills.
• Will be exposed to the following hazards on a frequent basis: mechanical, electrical, chemical, blood and body fluids. Will be required to wear protective clothing and equipment as needed.
• Operates all equipment necessary to perform the job.

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.