Medical scribe job description

Job DescriptionThe Dermatology Medical Scribe duties include performing all clerical and information technology functions for and under the direction of a physician by documenting in the electronic medical record (EMR). Medical Scribes must be professional and discreet 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 required when working as a Medical Scribe
PRINCIPAL DUTIES AND RESPONSIBILITIES:

Document in the EMR for the physician during patient clinical visits or encounters. This includes documenting the patient medical and social history, physical exam, assessment and plan, diagnoses, medications, results, procedures, and treatments, and follow-up instructions. The medical scribe will be expected to learn and understand basic documentation requirements.

Works to facilitate patient flow and ensure an accurate and complete medical record for each patient. Accompanies physician into patient examination room to accurately document the physician's encounter with the patient and others present following established policies and guidelines. Lists all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by physician. Document physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications, and allergies during the visit exam. Document all procedures performed by physician. Document physical examination findings and procedures as performed by the physician. Document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient. Create and queue medication, laboratory, and other orders for physician to authenticate and initiate. All orders for patient care must be communicated by the physician and not the scribe. Create and maintain guide of Dermatology physician documentation preferences. Medical Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to transporting specimens, answering phones, assisting patients, calling physicians, etc.
Assists the provider with all clerical activities related to the EMR. To help support workflow and documentation for medical record coding. Assists provider in navigating the EMR and locating information such as tests, lab results, and hospital dictation. Responds to messages as directed by physician. Search and collect pertinent past medical histories, test results, external medical records, or other needed patient information requested by physician. Prepares referral letters and other patient care correspondence as directed by physician. Assists physician with obtaining or locating information in EMR or other systems as appropriate.
Ensures good teamwork and effective interpersonal relationships. Communicates effectively and handles confidential matters per policy and procedures. Recognizes sensitive situations and seeks appropriate guidance. Monitors personal work ethic, behavior, and attitude. Maintains strong and effective relationships with peers, staff, physicians, agencies, and other organizations consistent with MGB, BWH and Dermatology policy and standards. Works to improve patient satisfaction. Identify opportunities for process improvement related to quality initiatives. Actively participates in recommending plans of action to address any identified issues. Comply with all national and local PHI laws including in HIPAA and HITECH policy and standards. May perform other non-clinical tasks as directed by supervisor or designee.

Qualifications
High school diploma or equivalent is required, Bachelor's Degree desirable. Must be able to read, write legibly, speak clearly, and understand the English language. Based on physician and practice operational needs, may be asked to change work schedule and/or location. At times there may be little notice. Changes are typically short-term and long-term changes will be reviewed and discussed by manager. Previous EMR experience preferred. Completion of a medical terminology course or one year experience working with medical terminology in a clinical setting is highly desirable. Ability to multi-task and consistently communicate in a professional manner and perform duties under pressure. Adequate knowledge of computer usage and ability to tolerate viewing on computer monitors for extended periods of time. Able to establish and maintain collaborative working relationships with physicians, administrators, clinical managers, and other staff. Strong attention to detail

EEO Statement
Brigham and Women's Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability. Partner's Healthcare is acting as an Employment Agency in relation to this vacancy.

The principle duty and function of a Medical Scribe is to enhance the efficiency of his/her supervising provider.
Responsibilities:


Record a physician-directed or advanced practitioner directed patient history of present illness (HPI), past medical history (PMH), family and/or social history and physical examination (PE), including pertinent positives and negatives. Record procedures and the results of laboratory tests and radiographic images. Improve the efficiency of patient care by assisting the physician with routine matters. Serve as an ambassador/liaison between the physician, the patient and clinic staff. Will function at all times under a physician or advanced practitioners direct supervision. Will abide by all applicable Steward policies and procedures including, but not limited to, safety matters, HIPAA-compliance and patient/computer confidentiality.


Qualifications:


High school diploma or equivalent required Basic knowledge of medical terminology required Strong computer and typing skills required Strong written, verbal, and interpersonal communication skills with colleagues and patients required Strong attention to detail required Athena and Meditech experience preferred Successful completion of a Medical Assistant, EMT or CNA training program a plus but not required



About Steward Health Care


Steward Health Care is the largest private, for-profit health care network in the United States. The company is owned and led by a management team of Steward physicians. Headquartered in Dallas, Texas, Steward employs more than 40,000 health care professionals and operates 35 hospitals across the United States and in the countries of Malta and Colombia which regularly receive top awards for quality and safety. The Steward network includes multiple urgent care centers and skilled nursing facilities, substantial behavioral health services, more than 7,000 beds under management, and approximately 2.2 million full risk covered lives through the company's managed care and health insurance services.

The Steward Health Care Network includes more than 5,000 physicians across 800 communities who help to provide more than 12 million patient encounters annually. Steward Medical Group, the company's employed physician group, provides more than six million patient encounters per year. The Steward Hospital Group operates hospitals in Malta, Colombia and nine states across the U.S., including Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, Texas, and Utah. For more information, visit www.steward.org.


Additional Information


Steward Medical Group is taking additional necessary preparations to ensure patients can receive compassionate care in safe, carefully managed environment - with confidence and without fear.

Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience.

Any COVID-19 related care takes place in designated areas away from other patients and their families. A stringent cleaning policy has been implemented throughout our facilities. A strictly controlled visitor and mask policy is required for patient and colleague safety.

Scribes shadow resident physicians and attending physicians and completes all documentation tasks through real time, on-site medical transcription. Also responsible for ensuring thoroughness of medical documentation, coordination and integration of medical tests/labs/imaging for ready access of the physicians.

Shadows physicians during patient encounters and ensures that medical documentation is complete according to all appropriate guidelines. Takes notes on patients and completes the medical chart.
Performs random chart reviews for quality assurance medical documentation purposes. Keeps chart deficiencies to less than 5%. Assists the physician with communicating their patient care plans with other physicians, nurses and patient care technicians. Ensures patient care flow has optimal efficiency to keep patient care at a high quality and the efficiency of patient flow maximized. This will be monitored by physician semi-annual reviews. Provides timely submission and retrieval of tests on behalf of the physician. Performs other tasks as assigned.


MINIMUM REQUIREMENTS

Education:

High School Diploma or Equivalent

Experience:

Real-time scribe, medical or other type of chart or record creating experience

Licensure:

None

Skills:

Microsoft Office Suite (Word, Excel)


PHYSICAL DEMANDS

This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.


COVID Vaccination Requirement and Guidelines


Please visit the UVA COVID-19 Job Requirements and Guidelines webpage prior to applying for current information regarding vaccination requirements and guidelines for employment at UVA.

The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician's Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.