• The primary role of the scribe is to assist the provider with documentation of each patient's clearly recording each patient's symptoms, history, physical exam, and documenting the diagnosis as well as treatment plans in the medical record during a clinic visit.
• At the start of the visits scribes checks the “document scribed” checkbox on the intake template at the top center.
• Accompanies the clinician into the patient examination area, or joins the appointment remotely by telephone, in order to transcribe a history and physical examination as given by the patient and provider.
• Under the direction of the provider, transcribes and places patient orders, including laboratory tests, radiology tests, referrals, etc.
• Documents any procedures performed by the provider or nurses in the EHR.
• Transcribes any consultation or discussions with family and/or the provider.
• Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient's workup complete so that the provider is able to make his/her decisions regarding that patient.
• Scribe lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
• Scribe does not directly assist with patient care. The scribe documents orders generated by the provider.
• Scribe assists the provider and support staff with paperwork, telephone calls, faxing, and chart abstraction and may facilitate communication among the care team.
• Scribe is able to process portal communications and either task to appropriate member of the care team or get information from the provider to respond to the patient in a timely way.

• Medications: A scribe cannot prescribe medications. Scribes cannot stop, start, or make any manipulation to any medications in the "medication module”.
• Orders: A scribe cannot order any in-house medications that are injected, ingested, or inhaled into the body including nebulizer treatments.
• Document Sign Off: The provider should always review the record and attest to its correctness and completeness. At the end of the day or shift, the provider should review the scribed documentation to ensure all events were recorded accurately. The provider generates the document, creating the completed "Master IM." The scribe does not.
• Patient Care: The scribe is not directly involved with patient care; can’t touch the patient; can’t handle bodily fluids; can’t act independently without direct clinical oversight; conduct other duties while acting as the medical scribe; however, he/she may be asked to give patient paperwork during visit or discuss discharge instructions with a patient. The scribe can’t give orders to Registered Nurses. They interact with patients on a limited level. For exceptions to this section, please see the “Optional Trainable Skills” section below.
• General Documentation: A scribe cannot document any of his/her personal objective findings or be involved in any of the medical decision-making. A scribe cannot act independently; instead, he/she must simply document the provider’s dictation and or/activities during the visit.

• Other duties as assigned

Education and Experience:

• High School Diploma or Equivalent (GED) required.
• Experience with EPIC Electronic Health Records preferred.

Required Skills and Abilities:

• Must be able to communicate effectively in English (able to read, write and speak).
• Bilingual in Spanish a plus.
• Ability to multi-task work duties.
• Ability to work as a team.
• Excellent interpersonal skills.
• High attention to detail.
• Excellent follow-up ability.
• Ability to use a computer and work with electronic health records.

Physical Requirements and Working Conditions:

• Must be able to lift up to 25 pounds at times.
• Prolonged standing, walking, and prolonged periods sitting at desk and working on a computer.
• Ability to work in a fast-paced environment.