Scribe Job at Healogics, Inc
Job Summary:
The Scribe aaccompanies the physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present. The Scribe lists all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. They also transcribe patient orders including laboratory tests, radiology tests, medications, etc. and document any procedures performed by the physician.Essential Functions/Responsibilities:
- Prepares and assembles medical record documentation/charts for physician(s).
- Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
- Ensures medical record compliance by self-documentation attestation.
- Updates patient history, physical exam, and other pertinent health information in the patient chart.
- Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
- Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
- Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
Required Education, Experience and Credentials: (typically includes the following language)
- High school diploma, GED, or equivalent
- Knowledge of medical terminology and human anatomy a plus
- Skilled in operating various medical record software and hardware, word-processing, and database software programs
Required Knowledge, Skills and Abilities: (typically include:)
- Administrative writing skills
- Reporting skills
- Organizational skills
- Record-keeping
- Microsoft Office skills
- Professionalism, confidentiality, and organization
- Typing
- Verbal Communication
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