Job Description

Job Description

Job Description

Job Description

Title: Medical Scribe

Department : Medical
Status : Hourly
Position Classification/Category : Clinical
Location: Onsite
Reports To : Practice Manager

Direct Reports : None

Summary of Position: Medical Scribes are individuals trained in medical documentation who assist a physician throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient. Include performing 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. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job since you will be hard to replace.

Education / Qualifications: Certification from a Medical Scribe Professional Training Program or American College of Medical Scribe Specialists (ACMSS) or a minimum experience of 1 year of equivalent-on-the-job experience.

Language Skills: The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.

Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.

Computer Skills: To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.

Key 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.
   • Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.

1. Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record.

1. Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.

1. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

1. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.

1. Attend training on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

1. Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.

1. And other duties as assigned

Kintegra Health Core Requirements

1. Patient First – An approach to care that holds primary, the well-being and desires of the patient
2. Build not Blame – Focusing first on finding fault with the process rather than the person
3. Integrity and Honesty – F ostering an acceptance of openness, honesty, and fairness in words, deeds and the use of organizational resources judiciously for both internal and external customers
4. Cooperation and Flexibility – Related to an internal believe that we function as part of an interdependent team with only shared gains or losses thereby committed to assisting whenever possible beyond the prerequisite job description
5. Culturally Sensitive – Always working toward increasing one’s ability to understand, communicate with, effectively interact, and care for people across cultures; while having an acute awareness of one’s own culture.

Kintegra Health is a is a community sponsored, family-centered provider of health care, health education and preventive care services without regard to the ability to pay. We screen potential employees to ensure alignment with our core requirements followed by the requisite position skills set. In doing so we need staff committed to this mission who do their best to live and work on the characteristics of our core values as we strive to care for ever increasing members of the communities we serve.

Our goals are:

• To provide continuing comprehensive and accessible primary care services to individuals and families of all economic levels within Gaston County.
• To provide primary care services to meet the physical as well as social health needs of individuals and families, promoting health maintenance, providing timely diagnostics, treatment and referral services.
• To emphasize preventive care through patient and community education to help individuals become aware and responsible for their own health behaviors.
• To employ an interdisciplinary team approach in collaboration with other community providers to provide a continuum of appropriate patient/family-oriented care in a cost-effective manner.

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