Medical Scribe shall contribute to a stable workforce tasked with providing quality health care services.
• Attend and participate in patient care conferences, team conferences, and discharge planning, as deemed appropriate by specific area assigned to work.
• Accompany the physician upon patient interview and examination.
• Document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
• Document physical examination findings and procedures as performed by the physician.
• Document the results of laboratory and radiographic studies as dictated by the physician.
• 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 that you completed, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.
• The physician and you shall 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.
• You shall not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians.
• 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.
• Participate in ongoing educational opportunities as offered by the Medical Center.
• Attend regularly scheduled staff meetings.
• Be responsive to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician, ancillary hospital staff, and other Medical Center staff.
• Must be a high school graduate, and have completed a medical terminology course or one year medical terminology experience in a clinical setting.
• Must have excellent and legible penmanship and have the ability to multi-task and communicate in a professional manner.
• Have and maintain current certification American College of Medical Scribe Specialists (ACMSS).
• Must have completed a medical terminology course or one year medical terminology experience in a clinical setting.
• Must understand, speak, read and write English fluently.