Medical Scribe: OCW Talega OBGYN

Primary Duties And Responsibilities

The Medical Scribe acts as the personal assistant to the physician performing all documentation functions in the EHR system in a complete and timely manner. The Scribe accompanies the Physician into the patient examination room and accurately transcribes the history, physical exam, documents the encounter and others present with the patient at the time. Documents all procedures performed and advice provided by the Physician.

Document physical examination findings and procedures as performed by the physician.

Document the results of laboratory and radiographic studies as dictated 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.

Lists all proper diagnoses and symptoms as well as follow-up instructions and prescription as dictated by the Physician.

Transcribes patient orders including laboratory results, radiology tests, medications etc.

The Scribe maintains a working knowledge of departmental standard operating procedures. This knowledge may include the use of specialized instrumentation, Quality Control requirements, and preventive maintenance. Performs other duties as assigned.

Qualifications

• Education and Experience
• High school graduate or equivalent
• Minimum six (6) month’s experience as a Medical Scribe, or equivalent training, experience, and education
• Working knowledge of The EHR system and Outlook required
• Ability to Read/Interpret documents, write reports/correspondence, speak concisely and clearly.
• Ability to Listen effectively and interface with the Public required
• Fast, accurate typing, transcription skills, filing, and phone skills required
• License Required: N/A
• License Preferred: N/A
• Certifications Required: N/A
• Certifications Preferred: BLS – AHA Basic Life Support