Medical Practice Scribe

Overview

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.

Reports to the Operations Manager

• 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.

• High School graduate or GED required.
• Completion of a medical terminology course is preferred, or previous medical terminology experience in a clinical setting.

• Ability to multi-task and consistently communicate in a professional manner.
• Excellent typing and language skills. Typing proficiency of 80-90 wpm.

• Normal office setting.
• Minimal lifting requirements.
• 50% sitting, 50% standing.

HIPAA1