Medical Scribe

Position Summary

Scribe accompanies physician in the outpatient clinic and documents during patient visits, ensures medical records are up to date and complete, prepares notes for providers, and completes follow-up activities (e.g., referrals, orders, appointment scheduling) in a timely manner.

Position

• Scribe
• Department:
• SEMC
• MDs
• Schedule:
• Part
• Time
• Essential
• Responsibilities /
• DUTIES: Preps office notes for all in-person and TeleHealth clinics. Obtains interval laboratory results, MRI, and EEG results, and enters them into the chart at least 24 hours prior to the encounter to allow for clinician review. Performs accurate, real-time charting of patient encounters. Adheres to all required guidelines for proper documentation to allow for accurate reporting and billing. This includes detailed recording of the elicited history, physical examination, diagnostic testing results, and appropriate and comprehensive summarization of the ensuing discussion and plan developed by the patient and provider. Ensures that all required test orders, prescriptions, and other required referrals are placed in the medical record during and immediately following the encounter, ready for the provider to sign. Ensures that copies of the encounter documentation are presented to the patient, to their primary care provider, and to all other care providers for the patient. Ensures that all documentation is grammatically correct with correct spelling; as copies of the notes are provided to the patient, thorough editing of the record ensures adherence to high quality standards and ensures accurate communication with other providers. After each clinic, the scribe will ensure that all referrals are sent to appropriate providers or their representatives, that EEG and MRI orders are conveyed to the epilepsy program coordinator, and that follow-up appointments are booked with the provider and/or epilepsy NP. When appropriate, the scribe may be asked to assist with confirming upcoming patient visits and/or with rescheduling visits if required test results are not yet available. (The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).
• JOB
• Requirements
• Required
• Education
• AND
• EXPERIENCE: High school diploma or equivalent, and successful completion of a scribe course, required.