Clinical Documentation Specialist

Description JOB OVERVIEW

• The Medical Scribe role assists a physician throughout their shift with medical documentation. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on the evaluation, management, and treatment of patients at The Orthopaedic Institute.
• Essential
• Functions
• INCLUDE,
• BUT
• ARE
• NOT
• LIMITED TO: Accurately and thoroughly document 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 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 Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned. Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar. Ensure all safety regulations are adhered to. Other duties as assigned