Job Details

Job Description

The Scribe assists the physicians and clinical staff by performing a variety of clerical tasks that ensure the efficiency of the unit. The Scribe verifies the patient's chart and ensures documentation meets appropriate coding requirements. Assists the physicians with documentation and organization of workflow enhancing throughput and customer service. Relies on established guidelines to accomplish tasks. Works under close supervision.

Responsibilities

Job Function:

1. Clerical/Technical Tasks: This will have been satisfactorily performed when...
   1. Physician documentation is completed consistent with policy including transcription of patient information and patient orders as dictated by the physician.
   2. Procedures done by the physician and/or nursing staff are documented at the time of occurrence including summaries of suture placement or advanced cardiac life support measures.
   3. Accompanies the Physician into the patient exam room to transcribe a history and physical exam as stated by the physician during the interview and exam of the patient as evidenced by correct documentation in the patient chart for H&P.
   4. The patient chart is completed by transcribing results of any lab, x-ray, other evaluations.
   5. Continuous checks are made on the progress of patient data to assist with the disposition of the patient.
   6. Charts are completed by the end of the shift without exception including proper diagnosis, discharge/follow up instructions, and prescriptions as dictated by the physician.
   7. All pertinent patient care information is communicated accurately at time of occurrence including complaints and general environmental information (hazards, breakage) to the staff, Manager/Charge Nurse.
2. Other Duties as Assigned: This will have been satisfactorily performed when...
   1. Other duties as assigned are completed.
   2. Patients are assisted by answering questions with clinical questions referred appropriately to the physician or nursing staff.

• Education: High School or equivalent
• Skills: Communication, Customer Service, Computer Skills. Knowledge of medical terminology. Able to use office equipment and multi-task.
• Training: Medical Terminology or related medical training preferred. EPIC