Medical Scribe

Summary

At Williamson Medical Center, our employees are smart, talented, compassionate, dedicated, and an overall joy to be around. We’re certainly blessed to have the best of the best working here from the cafeteria to the operating room. That's why we know you would be a perfect addition to our team!

Position Summary

The Medical Scribe performs all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. The Medical Scribe must be able to anticipate physician needs to facilitate the flow of clinic. The Medical Scribe must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. 

Requirements

• Bachelor’s degree in healthcare field preferred
• 2 years scribe experience preferred
• Successful completion of Medical Assistant training program an asset

Workplace Experience

• Experience with medical terminology
• Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.

Equipment and Skills Training

• Excellent computer skills

Physical Environment

• Stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear.
• Occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
• Regularly lift and /or move up to 10 pounds.
• Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

Physical Effort

• Impeccable verbal, written, and interpersonal skills
• Strong attention to detail
• Excellent bedside manner

Responsibilities

1. 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; and Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
2. Dictation/faxing/phone calls and clerical tasks, such as preparing referral letters as directed by the physician, via dictation or summary of the medical record. Ensure that letters are mailed or faxed timely to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.  
3. Ensure that all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record.  Alert physician when chart is incomplete.
4. Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
5. Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
6. Assist in developing and maintaining systems to track patient follow up and compliance.
7. Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents.
8. Keep patient information confidential.
9. Attend trainings as needed on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Attend trainings as needed on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Attend trainings as needed on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures.
10. Works well in a team environment eager to help others, and has the ability to work on various items at once.
11. Demonstrates responsibility for assigned communication.
12. Maintains open & effective communication to promote & maintain optimal patient safety & maximize operational efficiencies.

Williamson Medical Center is an equal-opportunity employer and a drug-free workplace.