Medical Practice Scribe
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AI Summary
The Medical Practice Scribe documents physician services and patient encounters in real-time within the EHR system. They are responsible for retrieving medical data and recording physician-dictated diagnoses and instructions while adhering to privacy policies.
The Medical Practice Scribe is responsible for functioning as a real time documenter of the physician services performed during a patient encounter in the medical practice environment. Responsible for accurately entering information into the EHR as dictated to them by the provider.
Job Relationships
Reports to the Operations Manager
Principal Responsibilities
- Accompany the physician during a complete visit encounter and document in real time the words, actions, physical examination findings, procedures and treatments as performed by the physician.
- Accurately enter information into the EHR as dictated to them by the physician. Document the physician's actions and words during the visit while in the presence of the physician. Enter the information into the EHR under his/her own log-in.
- Retrieve data for physician review such as labs, radiology reports and medical records. May transcribe a provider's consultations with other healthcare professionals, patients and family members.
- Record physician-dictated diagnoses, prescriptions and instructions for patient discharge and/or follow up.
- Will not touch patients or perform any clinical tasks.
- Must fully understand and adhere to the standard operating policies and procedures specific to ""Scribe: Guidelines for Use in the Medical Office.""
- Perform other clerical duties as assigned by operations manager, physicians and/or advanced practitioner.
- Comply with the Springfield Clinic incident reporting policy and procedures.
- Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
- Provide excellent customer service and adhere to SC Way customer service philosophy.
- Perform other job duties as assigned.
- Education/Experience
- High School graduate or GED required.
- Completion of a medical terminology course is preferred, or previous medical terminology experience in a clinical setting.
Knowledge, Skills and Abilities
- Ability to multi-task and consistently communicate in a professional manner.
- Excellent typing and language skills. Typing proficiency of 80-90 wpm.
Working Environment
- Normal office setting.
- Minimal lifting requirements.
- 50% sitting, 50% standing.
PHI/Privacy Level
HIPAA1
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