Medical Scribe/Medical Transcription
About the position
The Medical Scribe at Shea Clinic plays a crucial role in facilitating patient flow and ensuring accurate medical records. This position requires a professional with at least two years of experience in medical scribing or transcription, who will assist physicians during patient examinations by documenting medical histories, exam details, and coordinating necessary resources. The scribe's responsibilities are distinct from those of a Certified Medical Assistant (CMA).
Responsibilities
? Assist the physician with documentation of each patient's medical chart during their visit.
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? Record details of chief complaints, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications, and allergies.
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? Accompany the physician into the patient examination area to transcribe history and physical examination details.
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? Document the physician's encounter accurately, including pertinent positives and negatives, noted abnormalities, and patient general condition.
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? Transcribe patient orders under the direction of the physician, including laboratory tests, radiology tests, and medications.
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? Document any procedures performed by the physician on the medical chart.
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? Complete the patient's chart by transcribing results of labs, x-rays, or other evaluations.
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? List all proper diagnoses and follow-up instructions as dictated by the physician.
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? Troubleshoot causes and solutions if orders are not completed in a timely fashion or if results are incomplete.
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? Use E-prescribe in the practice management system to send prescriptions to the pharmacy.
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? Call in prescriptions/refills to the pharmacy under the direction of the physician.
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? Triage patient messages and manage patient telephone calls.
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? Provide reports to the physician prior to patient exams and assist with pre and post-op patient education.
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? Have imaging studies available on the physician's laptop prior to patient exams.
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? Assist with minor in-office procedures and have patients sign consent forms.
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? Communicate problems with patients, physicians, or other personnel to the Site Manager.
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? Maintain confidentiality, security, and physical safety of all patients and patient information.
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? Organize and maintain the work area and back up team members in their absence.
Requirements
? Must have 2 years of Medical Scribe experience.
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? Working knowledge of medical terminology and accepted abbreviations.
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? Ability to recognize the physical exam process and record exam details.
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? Strong communication skills and ability to coordinate with multiple members of the healthcare team.
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? Organizational skills with a focus on tracking patient care and improving patient flow.
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? Professional demeanor and recognition of privacy considerations for patients and families.
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? Typing and general computer skills with good grammar, punctuation, and spelling.
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? Excellent English language skills and strong interpersonal communication skills.
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? Ability to multi-task and be self-directing and proactive after understanding goals.
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? Willingness to learn the basics of ENT.
Nice-to-haves
? High school diploma or equivalent (Preferred)
Benefits
? 401(k)
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? Dental insurance
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? Health insurance
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? Paid time off
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? Vision insurance
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