Location
Upper Moreland Township, Pennsylvania
The Medical Scribe is responsible for accurately documenting medical visits, procedures, and progress notes to increase physician efficiency. They also handle administrative tasks such as pending medications, lab work, and assisting patients with follow-up instructions.
Candidates should be PreMed or PrePA students, preferably with a Bachelor's degree, who are currently in a gap year. A personal vehicle and a one-year commitment are required.
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician. Preparing progress notes for physician: Will identify reason for patients visit, ongoing patient problems, changes to medication, orders placed during last visit. Start progress note including initial history of prior illness (HPI), laboratory studies, and other studies, and ICD/problem list for physician. Physician reviews prior records, laboratory studies, other studies, initial HPI and ICD(ongoing problems) list. Begin visit with physician: HPI section must include location, quality, severity, duration, timing, context, precipitating/modifying factors, and associated signs and symptoms. Must also include any other details physician wants to take record in progress note. Be able to record any findings physician has for review of systems and physical exam. Begin assessment for physician: “Pend” medications, tests, and lab work as requested by physician. Prepare and print out any related patient instructions/ after visit summary/lab orders as requested by physician. “Pend” progress note for physician to personally review and sign. Patient follow up: Help patient with any questions on follow up visit. Ex. lab testing locations/medication protocol/follow up visit date.
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