Clinic Scribe/Rn/Lpn/Cma

Clinic Scribe

The duties of the Clinic Scribe are to document the physician dictated patient history, physical examination, family social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the physician/provider and any other information pertaining to the patient’s encounter. This non-exempt position reports to the Assistant Practice Manager and is part of Family Practice Associates clinic operations.

The Clinic RN/LPN/CMA works as part of the medical office team performing clinical and clerical duties to meet the goal of providing primary health care. Duties include preparing patient for provider visit, gathering information, assisting providers with procedures, answering the phone, making appointments, registering patients, performing laboratory procedures and giving injections. May call in patients prescriptions as directed by provider.

Education: Graduate from an accredited RN, LPN, or CMA program. Possess current licensure or certification.

Experience: 1-2 years experience in physician’s office or related experience, preferred, but not required.

Experience/Skills

• One year experience in office or hospital setting
• Ability to multi-task and consistently communicate in a professional manner.
• Completion of a medical terminology course or one-year medical terminology experience in a clinic setting
• Excellent and legible penmanship
• Ability to check and respond to all correspondence, including email, phone calls or text messages in a timely manner.
• Demonstrates the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state and federal guidelines for documentation.
• Demonstrates an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
• Demonstrates organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
• Beneficial to have background in medical-surgical nursing and immunizations. Knowledge of clinic function and ability to workin conjunction with other clinic personnel. Knowledge of community health resources for alternate health services and knowledge of community health nursing principles and practices.

ROUTINE RESPONSIBILITIES

      Behavioral Expectations

• Consistently complies with established Behavioral Expectations

      Essential Functions

• Accompanies the physician/provider upon patient interview and examination.
• Documents the physician/provider dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications, and allergies.
• Documents physical examination findings and procedures as performed by the physician/provider.
• Documents the results of laboratory and radiographic studies as dictated by the physician/provider.
• Documents the correct time of patient care related activities, including physician/provider to physician/provider communication, family communication and re-examination of the patient.
• When the physician/provider concludes the patient’s encounter, the physician/provider will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician/provider is ultimately responsible for documentation of the patient’s encounter.
• The physician/provider and the Scribe will make “chart rounds” to review patient status, delays, and any other care-related issues.
• All orders for patient care must be communicated by the physician/provider and not the Scribe.