Job Description
POSITION DESCRIPTION:
The number one job of a Medical Scribe or AMA is to transcribe all that is happening into the medical records using a WOW or workstation on wheels system. The system is wheeled around with the scribe so that they can document everything accurately into the medical records of the patient. This makes the medical records more accurate and allows the doctor to provide a higher level of care and attention to the patient.
Major Areas Of Responsibility
A Medical Scribe is a medical professional that offers services to help a doctor to provide a higher level of care by taking care all of the paperwork that they would normally have to do on their own.
Medical scribes perform a wide variety of transcription related tasks such as inputting patient data (such as history or symptoms), recording examination results and preparing charts. Depending on the facility and company, this may involve electronic forms of documentation or physical paperwork, but organizing and cataloging are generally a large part of the job. The daily operations of the position involve close work with physicians and other employees in the medical environment.
Primary Objectives
- Comply with all legal and ethical requirements for medical documentation.
- Alert physician when medical record is incomplete or medical documentation contains mistakes or inconsistencies.
- Collect, organize and catalog data for physician quality reporting system and other quality initiatives to increase patient compliance and improve outcomes.
- Document medical visits and procedures as they are being performed by the physician accurately and thoroughly.
- Perform clerical tasks as needed by the physician including faxing, phone calls and referral letters.
Required Knowledge, Skills And Abilities
- Medical Office: 1 year experience
Required License Or Certification
- Medical Assistant Certification
Required Education
- High school or equivalent
Education And Experience
- Medical transcription, coding or terminology required
- HIPAA Compliance training
- Courses in Medical Chart compliance
Soft Skills
- Excellent skills in communication (the ability to communicate with several types of medical professionals)
- The ability to work well as part of a team
- Writing abilities
- Computers and data management training
- Must be able to type >50 WPM
PHYSICAL DEMANDS
- These physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of the job. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions.
- While performing the responsibilities of the job, the employee is required to walk, talk, see and hear. Reaching for medical equipment is required, along with occasional bending and stooping.
WORK ENVIRONMENT
- While performing the duties of this job, the employee is occasionally exposed to blood and other bodily fluids, the use of needles which exposes the employee to punctures.
- There may be lots of time spent on their feet and walking from room to room shadowing doctors. The majority of medical scribes work in hospitals and in doctor’s offices but they can also work in outpatient care centers and labs. Work schedules are typical of that of a doctor since you will be with the doctor for their whole shift. This can be from eight to twelve hours a day. Some medical scribes do work part time hours. Typically this will be from forty to sixty hours per week depending on the doctor that you work for.
RESPONSIBLE TO
- Medical Doctor, Office Manager
SUPERVISORY RESPONSIBILITY
- The position has no supervisory responsibility
Job Type: Full-time
Work Location: In person