Location
Columbia, SC | United States
Job description
Description
JOB SUMMARY
The Scribe works to facilitate patient flow through the clinic and ensure an accurate and complete medical record for each patient. The Scribe assists the physician by accompanying them during the medical history-taking and exam, recording details into the medical record, and coordinates resources regarding tests, orders, radiology and results. Performs all essential functions of a Medical Assistant.
JOB RESPONSIBILITIES
- The primary role of the medical scribe is to assist the physician with documentation of each patient's medical chart during his or her stay visit.
- Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies.
- Accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
- Documents accurately the physician's encounter including pertinent positives and negatives, noted abnormalities and patient general condition.
- Under the direction of the physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc.
- Documents any procedures performed by the physician on the medical chart.
- Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations.
- Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the physician.
- Physician approves every task of the scribe and takes full responsibility, with their signature, for the information recorded in their patients' charts.
- If orders are not completed in a timely fashion or if results are incomplete, troubleshoot for causes and solutions.
- Use E-prescribe in practice management system to send prescriptions to pharmacy
- Under the direction of the physician, calls in prescriptions / refills to pharmacy
- Triage patient messages utilizing approved protocols
- Under the direction of the physician, reviews patient messages
- Manages patient telephone calls
- Provides reports to physician prior to patient exam
- Provides pre and post op patient education and education material
- Have imaging studies available on physician's laptop, ready to view prior to patient exam
- Assist with minor in office procedures, numb patients with Pontocaine
- Have patient sign consent forms
- Performs all duties of a Medical Assistant.
- Volunteer for special projects or committees.
- Communicate problems with patients, Physicians or other personnel to the Site Manager.
- Maintains the confidentiality, security, and physical safety of all patients and patient information.
- Organize and maintain work area.
- Back up team members in their absence.
- Work assignments and prioritize.
Experience: Working knowledge of medical terminology and accepted abbreviations. Recognition of physical exam process and ability to record exam details Communication skills and the ability to coordinate and cooperate with multiple members of the health care team. Organizational skills with focus on tracking patient care and improving patient flow. Professional demeanor and recognition of privacy considerations for patients and families. Typing and general computer skills. Good grammar and punctuation and spelling. Excellent English language skills. Strong interpersonal communication skills. Ability to multi-task. Self-directing and pro-active after understanding goals. Willingness to learn the basics of ENT.
Requirements • High school graduate, Certification in Medical Assisting or related medical field
• Excellent typing and grammar skills
• Ability to multi-task and consistently communicate in a professional manner
• Completion of a medical terminology course or one-year medical terminology experience in a clinical setting
Job tags
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