Scope/Impact
The Medical Scribe will perform a wide variety of transcription related tasks such as inputting patient data, recording examination results, preparing, organizing and cataloging charts and electronic forms. Medical Scribes will assist in the daily operation of the clinic, working closely with the physician and nursing staff.
Job Functions
- Compliant with all legal and ethical requirements for medical documentation in an accurate, detailed and timely manner.
- Operates under the medical scribe scope of practice in accordance with AHIMA guidelines. Collect, organize and catalog data for the physician quality reporting system to ensure quality and increase patient compliance and improve outcomes.
- Document medical visits and procedures as they are being performed by the physician accurately and thoroughly.
- Perform clerical tasks as needed by the physician, including but not limited to faxing, returning calls and referral letters.
- Must have strong computer and typing skills.
- Must have efficient work organization and time management skills.
- Must be able to effectively communicate with co-workers, staff, patients and visitors.
- Perform any other duties as required or assigned by supervisor.
License(s) / Certification(s) / Registration(s)
Required: High school diploma or equivalent. Certified Medical transcription, CHDS Certified Healthcare Documentation Specialist) or a minimum of 5 years MA experience with medical documentation.
Education Required
Required: Certification as a Medical Assistant, Medical Transcriptionist or Medical Scribe (CHDS or ACCIM) with a minimum of 2 years’ experience in the field. Must have working knowledge of EHR’s.
Amount and Type of Experience
Required: Ability to type using keyboard at least 30 wpm and proficient in the use of computers and EHR’s.
Must have excellent grammar, spelling, punctuation skills and knowledge of medical terminology. Excellent verbal and written communications.