Job Summary/Objective:
The Medical Scribe works to facilitate patient flow through the clinic and ensure an accurate and complete medical record for each patient. The Scribe assists the physician by accompanying them during the medical history-taking and exam, recording details into the medical record, and coordinates resources regarding tests, orders, radiology and results.

Essential Job Functions

Assists the physician with documentation of each patient’s medical chart during his or her stay visit. Frees up a physician's time by handling data management tasks, so the physician can increase their patient contact time, think more thoroughly about cases, manage patient flow, and increase overall productivity. Collects, organizes and catalogs data for physician quality reporting system and other quality improvement efforts and format for submission. Spots mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.

• Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies.
• Accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
• Documents accurately the physician’s encounter including pertinent positives and negatives, noted abnormalities and patient general condition.
• Under the direction of the physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc.
• Documents any procedures performed by the physician on the medical chart.
• Completes the patient’s chart by transcribing results of any labs, x-rays, or other evaluations.
• Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the physician.
• Ensures that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. All addenda must be signed off by a physician.
• Alerts physician when chart is incomplete.
• Complies with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

Prepares referral letters as directed by the physician, via dictation or summary of the medical record and also ensures that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.

• Prepares referral letters as directed by the physician.
• May be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Medical scribes are basically data care managers enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours.
• Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
• Assists in developing and maintaining systems to track patient follow up and compliance.
• Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Required Education and Experience

• High School graduate or equivalent
• Two years of transcription and/or editing experience

AAP/EEO Statement
In order to provide equal employment and advancement opportunities to all individuals, employment decisions at SFENTA will be based on qualifications and job-related abilities. SFENTA does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, ancestry, sexual orientation, marital status, gender identity or any other characteristic protected by law. SFENTA will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in undue hardship.

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