Medical Scribe acts as an assistant during the examination and treatment of patients under the direction of a physician. Documents and gathers information during the treatment process. Being a Medical Scribe organizes healthcare data to provide better service and efficiency of clinical care. Typically requires an associate degree. Additionally, Medical Scribe may require certification as a Medical Scribe by the American College of Clinical Information Managers (ACCIM). Typically reports to a physician. The Medical Scribe works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be a Medical Scribe typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
We are seeking a Medical Scribe (FULL TIME) to assist us at our pain management clinic. This would be a scribing role to include but not limited to organizing and dictating/typing physician notes and submitting procedure orders.
Responsibilities:
● Scribes accompany the physician upon patient interview and examination.
● Scribes document the physician's dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
● Scribes document physical examination findings and procedures as performed by the physician.
● Scribes document the results of laboratory and radiographic studies as dictated by the physician.
● Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
● When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments for the provider to sign the chart.
The physician is ultimately responsible for documentation of the patient’s encounter. The physician 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 physician and not the Scribe.
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 physician.
● Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.
● Communicate in a professional and respectful manner to the supervising physician, ancillary hospital staff.
Knowledge/ Skills/ Abilities:
● Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and 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 multiple forms and paper documentation related to patient care.
Please submit a copy of your resume. Thank you.
Job Types: Full-time
Benefits:
● Health insurance
● Paid time off
● Paid training
Schedule:
● 8-hour shift
● Holidays
● Monday to Friday
Job Type: Full-time
Pay: From $16.00 per hour
Expected hours: 40 per week
Benefits:
Medical specialties:
Schedule:
Work setting:
Experience:
Work Location: In person
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