Summary: The Medical Scribe is responsible for documenting provider dictated health informationinto the Electronic Medical Record (EMR) and other information pertaining to a patient's encounter in the medical setting.
Responsibilities and Duties:
- Accurately and thoroughly document medical visits and procedures as they are being performed by the provider in real time, including but not limited to patient history, physical examination findings and procedures, laboratory and radiology studies, assessment and plan.
- Capture all medication orders, laboratory tests, imaging studies, consults, and procedures in the EMR as directed by the provider.
- Reinforces provider instructions and provides patient education as directed by the provider.
- Periodically participates in continuing education to improve skills in providing quality documentation.
- Attends and participates in various meetings as needed.
- Works within the Care Teams to create and sustain a Patient Centered model of quality health care.
- ?Demonstrate the knowledge and skills required to document clinical encountersunder the direction of a provider, included but not limited to anatomy, medical terminology, medication names.
- Be able to maintain confidentiality and privacy in accordance to HIPAA regulations.
- Be willing to complete a medical scribe course that qualifies one to take the national scribe certification exam by the Americal College of Medical Scribe Specialists (ACMSS)
- Must be competent with computers.
- High proficiency typing skills.