Medical Scribe

JOB SUMMARY

The Medical Scribe works side-by-side with a Cardiac Thoracic Surgeon as they see patients. The Medical Scribe provides real-time charting by shadowing the physician throughout their schedule and performs tasks including recording the patient's history and chief complaints, transcribing the physical exam, ordering x-rays, recording diagnostic test results, and coordinating with departmental resources regarding tests, orders, radiology and results. May perform patient care duties for the department under the direct supervision of Nursing or other medical staff, as requested.

Accompanies the physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician's encounter with the patient and detailed information including any procedures performed by the physician. Lists all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. Records details of physical exam, including pertinent positives and negatives, noting abnormalities and patient general condition.

Adheres to HIPPA laws.

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.

Transcribes and facilitates patient orders including laboratory tests, radiology tests, medications and referrals; submits orders as desired by medical provider; and checks constantly for results of those orders. If orders are not completed in a timely fashion or if results are incomplete, troubleshoots for causes and solutions.

Performs some patient care duties for the department, as requested.

• Certified Medical Assistant preferred.
• Quick Learner.
• Knowledge of medical terminology.
• Requires knowledge of HIPPA laws.
• Excellent computer skills.
• Impeccable verbal, written, and interpersonal skills.
• Strong attention to detail.
• Excellent bedside manner.
• Organizational skills with a focus on tracking patient care and improving patient flow.
• Excellent listening skills.
• Capable of typing at least 50 words per minute or faster.
• Team player.
• Ability to accept feedback and respond appropriately.
• Epic experience.
• MP/PA Experience is a plus.

• Education - H.S. Diploma/GED Equivalent
• Experience - Minimum of 1 Year of Experience