Medical Scribe at ScribeMD

Scribe Job Description

The duties of a ScribeMD Medical Scribe are to document the patient history and physical examination findings, as well as procedures, lab results, radiologic impressions and any other information pertaining to a patient’s encounter in the Emergency Department or other clinical medical setting.  Scribes are not patient care providers, nor are they part of the hospital staff; they are solely employed by EMSOC/ScribeMD.

Outline of Essential Functions:

1. Scribes are assigned to work with one physician/allied health provider ("provider") per shift.
2. Scribes accompany a provider to a patient exam room to document the patient dictated history, provider dictated physical examination findings, results of laboratory and radiologic studies, and procedures as performed by the provider.  
3. Scribes document the correct timing of all patient care related activities, including provider to provider communication, patient and family communication and re-examinations of the patient.  
4. All orders for patient care must be communicated by the provider and not the Scribe.  Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible provider or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc.
5. When the physician concludes the patient's encounter, the provider will review all documentation completed by the Scribe, make necessary amendments, and sign the chart.  The supervising physician is ultimately responsible for the documentation.

Additional Responsibilities:

1. Maintain and demonstrate an understanding of the team approach to patient care and documentation.
2. Participate in ongoing educational opportunities as offered by EMSOC/ScribeMD including attendance at staff meetings.
3. Be responsive to improvement opportunities in a positive manner.
4. Communicate in a professional and respectful manner to the supervising provider, ancillary hospital staff and EMSOC/ScribeMD staff. 

Knowledge/ Skills/ Abilities:

1. Demonstrate the knowledge and skills necessary to document patient care as dictated by a provider in a clear manner, following all local, state and federal guidelines for documentation.
2. Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
3. Demonstrate organizational ability to maintain and coordinate both electronic and paper records related to patient care for multiple patients at a time.

Minimum Position Qualifications:

1. High school graduate
2. Minimum one year availability to work.  
3. Minimum availability to maintain two shifts per week.
4. Ability to multi-task in a high stress, fast paced environment.
5. Moderate to upper level computer skills with the ability to tolerate viewing a computer monitor for extended periods of time.
6. Basic to intermediate knowledge of medical terminology.

Preferred Position Qualifications:

1. Healthcare Bound Student - physician, nursing, physician assistant, healthcare administration, etc.
2. College level education including health or medical related courses.
3. Advanced knowledge of medical terminology (either obtained from a medical terminology course, on the job experience, prior scribe experience, etc).
4. Fluent in a foreign language, preferably Spanish, with willingness to obtain translator certification.
5. Willing to provide two plus year availability to work.

Terms of Employment:

1. Per-diem, non-benefited, at-will employee

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