Address
Form of workGENERAL SUMMARY
A scribe functions primarily to document the physician dictated patient history, physical examination, family, social, and past medical history. The scribe assists the physician with patient centered care by documenting and monitoring procedures, lab results and dictated radiographic impressions. The scribe works as part of a team with a common goal of offering patient-centered, timely care, in a safe and friendly environment. This position requires assisting the physician and other members of the team to provide relationship based patient-centered care. This may involve using multiple types of sophisticated equipment and handling various types of patients in a friendly and frequently stressful environment.
OTHER DUTIES AND RESPONSIBILITIES
Safely demonstrates awareness of specific safety concerns in department. Complies with MyMichigan Health safety guidelines.
Maintains department equipment as necessary.
Identifies and communicates concern regarding unsafe conditions or equipment promptly. Participates in medical center safety drills.
Utilizes appropriate lift equipment as needed.
Attends education days. Seeks opportunities for self-education and enrichment while sharing information with co-workers.
Accurately and thoroughly documents the medical visit and procedures as they are being performed by the physician, including but not limited to: patient medical history and physical exam, procedures and treatments performed by health care professional, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
Records all telephone interactions.
Reviews and checks the Electronic Medical Record (EMR) for mistakes or inconsistencies and checks to correct the information as necessary.
All addenda must be signed off by a physician.
Ensures that all clinical data, lab or other test results are accurately reflected in the EMR. Recognizes and displays pleasant, friendly and cooperative manner to public.
Maintains clean and tidy work spaces in the unit, including an inventory of room supplies.
Maintains orderly patient flow.
Cleans equipment.
Completes documentation as required.
Has an understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribes dictated reports.
Translates medical abbreviations into their expanded forms.
Supports the mission, goals, policies, and standards of MyMichigan Health.
Communicates identified problems to appropriate personnel and implements actions to assure patient needs are met.
Assists unit in maintaining the area according to Joint Commission standards.
Is familiar with all safety and emergency procedures in order to provide and ensure safe and secure environment for the patient and other staff members.
Observes fall safety precautions.
Demonstrates competency in Infection Prevention and Control Practices and Policies.
Possesses an understanding of infection prevention and control measures designed to prevent the spread of infectious diseases.
Follows hand hygiene policies and utilizes personal protective equipment as required.
Other duties as assigned.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
REQUIRED EDUCATION, EXPERIENCE, TRAINING AND SKILLS
High School Diploma or GED required. A college degree or enrollment in a college degreed program is preferred.
BLS required within 90 days of hire or transfer to position.
Experience with medical terminology is preferred.
Experience as a medical transcriptionist preferred.
Must have strong writing, reading and computer skills.
Knowledge of policies, and procedures as normally acquired through experience working in a medical center or similar setting.
Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.
Maintains confidentiality with all patient information and data obtained by following MyMichigan Health, State, and Federal guidelines.
Organizational skills with a strong attention to details are needed to prioritize workload.
Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear and understandable manner.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing is necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health blood borne pathogen and TB testing as required.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level: Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.
A scribe functions primarily to document the physician dictated patient history, physical examination, family, social, and past medical history. The scribe assists the physician with patient centered care by documenting and monitoring procedures, lab results and dictated radiographic impressions. The scribe works as part of a team with a common goal of offering patient-centered, timely care, in a safe and friendly environment. This position requires assisting the physician and other members of the team to provide relationship based patient-centered care. This may involve using multiple types of sophisticated equipment and handling various types of patients in a friendly and frequently stressful environment.
- (70%)* The scribe will work with one physician while maintaining a friendly customer-oriented attitude at all times. The scribe will accompany the physician into the patient examination room in order to transcribe a patient history, physical exam, and document the family, social and past medical history accurately from the physician's encounter with the patient and others present. It is expected that all team members will work together to provide the best possible care to MyMichigan Health's patients, families, visitors, staff, community members, and any other person that is encountered while representing MyMichigan Health. It is expected that at all times the scribe will treat every person they encounter with non-judgmental: kindness, compassion, respect, and relationship based care. The scribe will accurately document the correct time of patient care related activities, including physician to physician activities. The examination will be an important part of the documentation process.
- (20%)* When the physician concludes the patient encounter, the scribe will complete and present the medical record to the assigned physician. The physician will review all documentation and sign the record.
- (5%)* The Scribe is knowledgeable and compliant with all local, state, and federal regulations and guidelines. The Scribe maintains knowledge of MyMichigan Health Departmental and/or physician office's specific policies and procedures relating to the care provided, and maintains professional standards.
- (5%)* Scribes do not participate in direct patient care however they will assist with the no pass zone and other initiatives to improve the patient experience.
OTHER DUTIES AND RESPONSIBILITIES
Safely demonstrates awareness of specific safety concerns in department. Complies with MyMichigan Health safety guidelines.
Maintains department equipment as necessary.
Identifies and communicates concern regarding unsafe conditions or equipment promptly. Participates in medical center safety drills.
Utilizes appropriate lift equipment as needed.
Attends education days. Seeks opportunities for self-education and enrichment while sharing information with co-workers.
Accurately and thoroughly documents the medical visit and procedures as they are being performed by the physician, including but not limited to: patient medical history and physical exam, procedures and treatments performed by health care professional, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
Records all telephone interactions.
Reviews and checks the Electronic Medical Record (EMR) for mistakes or inconsistencies and checks to correct the information as necessary.
All addenda must be signed off by a physician.
Ensures that all clinical data, lab or other test results are accurately reflected in the EMR. Recognizes and displays pleasant, friendly and cooperative manner to public.
Maintains clean and tidy work spaces in the unit, including an inventory of room supplies.
Maintains orderly patient flow.
Cleans equipment.
Completes documentation as required.
Has an understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribes dictated reports.
Translates medical abbreviations into their expanded forms.
Supports the mission, goals, policies, and standards of MyMichigan Health.
Communicates identified problems to appropriate personnel and implements actions to assure patient needs are met.
Assists unit in maintaining the area according to Joint Commission standards.
Is familiar with all safety and emergency procedures in order to provide and ensure safe and secure environment for the patient and other staff members.
Observes fall safety precautions.
Demonstrates competency in Infection Prevention and Control Practices and Policies.
Possesses an understanding of infection prevention and control measures designed to prevent the spread of infectious diseases.
Follows hand hygiene policies and utilizes personal protective equipment as required.
Other duties as assigned.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
REQUIRED EDUCATION, EXPERIENCE, TRAINING AND SKILLS
High School Diploma or GED required. A college degree or enrollment in a college degreed program is preferred.
BLS required within 90 days of hire or transfer to position.
Experience with medical terminology is preferred.
Experience as a medical transcriptionist preferred.
Must have strong writing, reading and computer skills.
Knowledge of policies, and procedures as normally acquired through experience working in a medical center or similar setting.
Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.
Maintains confidentiality with all patient information and data obtained by following MyMichigan Health, State, and Federal guidelines.
Organizational skills with a strong attention to details are needed to prioritize workload.
Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear and understandable manner.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing is necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health blood borne pathogen and TB testing as required.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level: Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.
