Scribe - Orthopedics - FT

Responsibilities:

• The medical scribe is responsible for recording accurate patient progress notes verbalized by the physician’s interaction with the patient relevant to the chart. Progress notes may include history of present illness, physical exam findings, medical decision making, laboratory results, radiology findings, consultations and dispositions. The medical scribe does not interject his or her own opinions, impressions and does not interpret clinical information.  
• The medical scribe is a clerical related task whereby a trained medical professional transcribes verbal communications between the provider and the patient. The medical scribe may only perform scribe related tasks, once the physician enters the exam room. The scribe role is 100% scribe and is not to be asked to perform other duties such as injections, obtaining vitals, and authorizations.
• The medical scribe is required to review and comply with the Scribing policies and procedures defined by McLeod Health adhering to all policies and procedures at all times. The scribe, along with the provider, will acknowledge that he/she understands their responsibility as set forth by the policy.
• The scribe and provider will insert specific documentation, as outlined by the scribe policies and procedures, to acknowledge the patient information was transcribed by a scribe. The scribe and the provider will capture this documentation at the time of service in order to remain compliant with CMS guidelines.
• Performs all other duties as assigned by the practice manager.

 

Qualifications:

• Three (3) years office experience in a position dealing with the public.
• Post high school training in medical terminology preferred.

Requirements:
  Degrees:
    High School/Ged
  Memberships:
    Occupation Risk Assessment