Medical Scribe

The Medical Scribe is essential to the medical care team and the patient experience at our practice. Although they do not directly interact with the patients during the appointment, the Medical Scribe is responsible for documenting everything communicated during the visit into the patient chart. These notes are carefully compiled utilizing proper quality codes and dot text phrases. Active listening, general understanding of medical terminology, and efficient typing skills are essential to complete this aspect of your role. At times, the provider will require assistance from the Medical Scribe regarding ordering labs, sending referrals, pulling up test results. printing documents for the patient during the visit, etc. Overall, the Medical Scribe is there to support the provider and ensure that all important details within the visit are documented and discussed with the patient.

Expected Duties and Responsibilities

• Complete chart prep prior to patient arrival including (but not limited to): updating alerts and flags to Quality, printing lab and test results for the physician to review and entering chart prep in EMR to show tests and immunizations due.
• Always maintain professionalism both in your appearance and interactions with patients and staff. Within the clinic setting, it is expected that individuals in this role will wear medical scrubs or business casual attire.
• Maintain patient chart with pertinent information including (but not limited to): add/update diagnoses list, verify pharmacy for medication needs, HPI, physical exam, entering prescriptions refills and orders for labs or imaging, treatment plans, CPT II codes (when applicable), and follow-up appointments.
• Exhibit superior typing skills with little to no errors in documentation, making sure to accurately document what happened during the visit.
• Complete quality forms via paper and electronic form, when required.
• Review consult notes with provider prior to and following the appointment, printing copies as necessary.
• Utilize appropriate dot text phrases and HCC coding as part of the notetaking process during the appointment.
• Develop an awareness of medications, including generic medications, to ensure proper documentation for prescriptions and refills for patients.
• Take new messages and update previous messages as directed (via EMR and organization-wide communication system) utilizing the dot text for accurate message taking and route to proper provider/staff member(s)
• Demonstrate familiarity with diagnoses and codes that are covered by insurance for specific lab orders
• Adhere to all HIPAA and OSHA guidelines and regulations
• Follow safety quality improvement program as directed
• Participate in corporate and practice-based quality initiatives, as directed
• Participate in monthly department meetings with management and the physicians, as scheduled.
• Perform and complete additional tasks and projects directly or indirectly related to your position when assigned by the Clinical Coordinator or Practice Director