The Medical Scribe creates and maintains an Electronic Medical Record (EMR) under the direct supervision of an attending physician. Documents the patient's history as relayed by the physician. Scribes record what is elicited by the doctor. Scribes may not give patient care order, medical advice or engage in any direct patient care.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Documents patient encounters into the EMR.
- Captures the patient care encounter while coordinating the presentation of diagnostic data.
- May accompany the physician during medical history-taking and exam, recording detail of both into the medical record.
- Demonstrates courtesy and politeness to patients, visitors and other employees.
- Maintains open channels of communication with center administration and other company departments; Answers all inquiries in a professional and courteous manner.
- Participates in training and in-service education as required.
- Complies with Leon Medical Centers' policies and procedures and maintains confidentiality in accordance with state and federal laws.
- Participates in special projects and performs other duties as assigned.
- Excellent verbal and written communication skills.
- Working knowledge of medical terminology and accepted abbreviations.
- Recognition of physical exam process and ability to record exam details.
- Computer proficiency, accuracy and ability to quickly learn new applications.
- Organizational skills with focus on tracking patient care and improving patient flow.
- Ability to work both in a team environment as well as independently.
- Previous Electronic Medical Records experience preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
Completion an accredited Allied Health Program included, but not limited to: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Medical Coding (CPC) or related disciplines.
High school graduation.
Fluent in English and Spanish required.