Medical Scribe- Evergreen

Department: Medical
Classification: Non-Exempt
Reports to: Director of Nursing

The Medical Scribe assists their assigned physician by performing all clerical and information technology functions for the physician in a clinic setting. The primary goal of the Medical Scribe is to increase the efficiency and productivity of the practitioner (physician and/or mid-level provider). Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.

The Scribe must be adaptable and versatile and maintain good attendance. The Scribe must be able to anticipate the practitioner (physician and/or mid-level provider) needs to facilitate the flow of clinic.

• Participates in Care team huddles and initiates pre-visit planning workflow to ensure Physician Care Plan completion prior to visit whenever possible.
• Maintains confidentiality at all times.
• Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician, including but not limited to:
  • Patient medical history and physical exam;
  • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants;
  • Patient education and explanations of risks and benefits;
  • Physician-dictated diagnoses, prescriptions, and instructions for patient or family members for self-care and follow-up; and
  • Preparation of referral letters as directed by the physician.
• Performs dictation, faxing, phone calls, and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribes also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, with all copies of pertinent reports or tests attached. May be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and perform other clerical tasks as assigned.
• Monitors for mistakes or inconsistencies in medical documentation and checks to correct the information in order to reduce errors. All addenda must be signed off by a physician.
• Ensures that all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record. Alerts the physician when the chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and the legal and ethical requirements for preparing medical documents and keeping patient information confidential.
• Monitors physicians’ open encounters and PAQ and assists providers in addressing them to maintain compliance.
• Collects, organizes, and catalogs data for physician quality reporting and other quality improvement efforts and records information in the EHR and formats it for submission.
• Assists in developing and maintaining systems to track patient follow-up and compliance.
• Attends training on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing, and coding. Quickly assimilates new knowledge into processes and procedures. Medical Scribes proofread and edit all physician medical documents for accuracy, spelling, punctuation, and grammar.
• Participates in Care team quality improvement activities, including Care team performance on required clinical, operational, and financial measures.
• Performs any other duties deemed necessary by the immediate supervising physician/Nurse Manager.

The above reflects the general duties considered necessary to describe the principal functions of the job and shall not be considered a detailed description of all…