GENERAL DESCRIPTION OF POSITION:
This role supports 2 job descriptions. See medical assistant job description below.
A scribe is an unlicensed person hired to enter information into the patient’s medical record under the direction and supervision of a physician or licensed practitioner. Scribes act as assistants to the physicians and/or licensed independent practitioners by aiding them with data acquisition (navigating the EMR), and supporting workflow. A scribe does not and may not act independently but documents the physician’s or licensed independent practitioner’s dictation and/or activities.
Scribes also assist the physician or licensed independent practitioner in navigating the EMR and in locating information such as test results and lab results. They can support workflow and documentation for medical record coding.
DETAILED DESCRIPTION OF POSITION:
- This role is still bound to medical assistant duties where it is applicable.
- A scribe is non-clinical and unlicensed person who will not provide any hands-on-form of patient care
- Scribes follow the physician or licensed independent practitioner and record information into the medical record, with the goal of allowing the physician or licensed independent practitioner to spend more time with the patient and have accurate documentation.
- The scribe will ensure accurate and comprehensive real-time documentation of the patient- provider interaction.
- History of Present Illness
- Review of Systems
- Past Medical History
- Past Surgical History
- Medications and Allergies
- Social and Family History
- Vital Signs
- Physical Exam
- The scribe will 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
KNOWLEDGE, SKILLS AND ABILITIES:
- Has the ability to relate to the health needs of the client.
- Has the ability to read and understand health care charting and medical procedures.
- Must have the ability to provide care, patience, and understanding.
- Has the ability to effectively communicate.
- Able to perform basic health care procedures that relates to patient care needs according to nursing skill checklist.
- Experience with Microsoft Office Application ( Word )
- Ability to type 35 wpm
- Basic working knowledge of Medical Terminology
A scribe must have a high school diploma or GED. Even if the scribe has any health care certification, the scribe will not be permitted to act outside of their role while functioning as a scribe. Recommended 1-2 years of experience in a health care.
TYPICAL PHYSICAL DEMANDS:
Requires full range of body motion including handling and lifting patients, manual and finger dexterity and eye-hand coordination. Involves standing and walking. Occasionally lifts and carries items weighing up to 50 pounds. Requires corrected vision and hearing to normal range. Requires normal visual acuity and hearing. Requires exposure communicable disease or bodily fluids.
TYPICAL WORKING CONDITIONS:
Frequent exposure to communicable diseases, toxic substances, ionizing radiation, medicinal preparations and/or other conditions common to a clinic environment.