Address
Form of workMEDICAL SCRIBE
Stockdale Clinics LLC
Job Description
A Medical Scribe plays a crucial role in healthcare settings by assisting healthcare providers, such as physicians, nurse practitioners, and physician assistants, with documentation and administrative tasks. The primary responsibility of a Medical Scribe is to accurately record patient encounters, take notes, and input data into electronic health records (EHRs) in real time. By providing this valuable support, Medical Scribes help improve workflow efficiency, increase physician productivity, and enhance patient care.
Essential Functions:
- Documentation and Charting: Accurately and promptly document patient encounters, medical histories, physical examinations, diagnostic test results, treatment plans, and other relevant information into the EHR system.
- Data Entry: Enter patient demographic details, medical codes, medications, allergies, and other pertinent information into the EHR system, ensuring completeness and accuracy.
- Transcription: Transcribe dictated medical notes, patient instructions, and other healthcare-related information accurately and efficiently.
- Communication: Collaborate effectively with healthcare providers to obtain clarifications, verify information, and ensure comprehensive and accurate documentation.
- Record Maintenance: Organize and maintain patient records, ensuring proper filing, labeling, and storage of all relevant documents.
- Workflow Support: Assist healthcare providers with administrative tasks such as scheduling appointments, arranging referrals, preparing patient charts, and managing other clerical duties.
- Quality Assurance: Review documentation for completeness, clarity, and compliance with regulatory standards, making necessary corrections or additions as required.
- Adherence to Guidelines: Comply with healthcare facility policies, HIPAA regulations, and other relevant guidelines regarding patient privacy, data security, and documentation practices.
- Continuous Learning: Stay updated with medical terminology, procedures, pharmacology, and relevant healthcare regulations to ensure accurate documentation and efficient workflow support.
- Efficiency Enhancement: Identify opportunities to streamline documentation processes, improve data entry accuracy, and suggest innovative ideas to enhance overall workflow efficiency and productivity.
Qualification and Sills:
- Education: High school diploma or equivalent is typically required. Some positions may prefer candidates with an associate or bachelor's degree in a healthcare-related field.
- Medical Knowledge: Familiarity with medical terminology, anatomy, and physiology is highly desirable. Knowledge of common medical procedures, diagnostic tests, and medications is beneficial.
- Computer Skills: Proficiency in using electronic health record (EHR) systems, data entry, and transcription software. Strong typing skills and the ability to multitask efficiently.
- Attention to Detail: Excellent observational skills to capture and record accurate information during patient encounters, ensuring completeness and precision.
- Communication Skills: Strong verbal and written communication skills to interact effectively with healthcare providers, patients, and other members of the healthcare team.
- Time Management: Ability to work in a fast-paced environment, manage multiple tasks simultaneously, and prioritize effectively to meet deadlines.
- Confidentiality: Understanding and commitment to maintaining patient confidentiality and adhering to HIPAA regulations.
- Adaptability: Flexibility to adapt to changing workflows, new technologies, and varying healthcare specialties.
- Teamwork: Ability to work collaboratively with healthcare providers, nurses, and other staff members to deliver high-quality patient care.
- Professionalism: Demonstrated professionalism, integrity, and ethical conduct in all interactions with patients and healthcare professionals.
*Background Check: A background check will be conducted for candidates applying for this classification. This is to ensure compliance with organizational policies and regulations.
