GENERAL DESCRIPTION OF POSITION:
Reports to the LPN Supervisor and Director of Nursing. Supports workflow and documentation for medical record coding. Enters information into the patient’s medical record under the direction and supervision of a physician or licensed practitioner. Scribes also assist the physician or licensed independent practitioner in navigating the EMR and in locating information such as test results and lab results.
DETAILED DESCRIPTION OF POSITION DUTIES:
- Aides with data acquisition (navigating the EMR) and supports workflow.
- Scribes follow the physician or licensed independent practitioner and record information into the medical record.
- The scribe will ensure accurate and comprehensive real-time documentation of the patient- provider interaction which includes; history of present illness, review of systems, past medical history, past surgical history, medications and allergies, social and family history, vital signs, and physical exams.
- Ensure the appropriate EMR or chart is selected and setup with the most comprehensive set of available objective patient questionnaire; past medical history, vital signs, medication and allergies.
- Use the facilities’ EMR to obtain and providing accurately and timely updates to patients’ imaging studies and/or laboratory tests with notification to the provider.
- Assist the physicians with workflow by functioning as a liaison between the provider and the other MA’s.
- Locate SOAP Template in order to find DX code and be sorted, HPI, ROS, PE, and Assessment/Plan.
- Access the Assessment/Plan area to order labs, diagnostic studies, document impression, pt. details, and provider details.
- Calculate E&M Coding before the provider submits coding.
- Perform additional duties as assigned.
High School education or equivalent, accredited Medical Assistant Course and/or 1-2 years of experience in a health care setting and certified by American Association of Medical Assistants. Must maintain certification by either re-examination or continuing education credit (CEU). CEU are obtained by attending AAMA approved programs.
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