Job Description

Assisting physician/clinician in documenting details of the patient visit via the electronic medical record, and performs other related clerical duties to increase physician/clinician effectiveness, efficiency, and productivity for improved patient flow and satisfaction. Effectively communicating and ensuring the patient's clear understanding of the scribe role, in order to enhance the patient's experience and comfort level. Preparing and rooming the patient for exam by obtaining vital signs and gathering/documenting/updating pertinent health information (i.e. chief complaint, allergies, and/or medications). Performing laboratory procedures (i.e. strep test, wound culture, specimen collection, etc.) using principles of aseptic technique and standard precautions/infection control guidelines. Assisting the physician/advance practice provider (APP) with procedures and surgeries such as pelvic exams, allergy scratch testing, EMG, cautery, colposcopy, etc. Administering routine medications, under physician/APP orders, which may include but are not limited to immunizations, antibiotics, vitamins and topical agents. Providing basic patient instructions on the performance of routine tasks or skills. Following through with necessary procedure or test requests, pre-approved care algorithms, new appointment times and referrals to other facilities or services. Referring questions to registered nurses and physicians/providers per scope of practice guidelines and relays information back to patient as directed. Communicating with physicians and other members of the health care team to ensure smooth clinic flow and makes adjustments as necessary. Effectively communicating accurate and timely information with the patient. In accordance with policy, preparing and assembling medical record documentation/chart for physician prior to patient visit. Anticipating physician needs for patient visits by obtaining internal and external previous medical records and test results. Ensuring that all elements of documentation are complete and accurate. Entering the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications. Documenting the physician/clinician's communication with the patient using appropriate medical terms and phrasing. Preparing (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders. Documenting the correct follow-up instructions and level of service designation based on the physician/clinician's direction. Assisting in data entry from devices or other sources. Completing medical records for each encounter ensuring accurate and timely documentation. Under physician/clinician direction, updating patient history and other pertinent health information in the patient record. Preparing and sending all documentation for review and approval. Licenses & Certifications: LPN: Licensed Practical Nurse (LPN) license issued by the state in which the team member practices, and Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required. MA: Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required. Degrees: LPN: Advanced training beyond High School that includes the completion of an accredited or approved program in Practical Nursing. MA: Completion of an accredited or approved program in Medical Assistant. Knowledge, Skills & Abilities: Proficient computer skills including keyboarding, navigation within a windows operating system, use of electronic mail and electronic medical records systems. Excellent communication (written and verbal) and interpersonal skills. Ability to develop rapport and maintain positive relationships with a variety of patients, family, staff and physicians. Good organization, prioritization and problem solving skills. Ability to multi-task with frequent interruptions.

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