Medical Practice Scribe (16 Hours/Week)

Springfield Clinic; Springfield (IL); On-site; USD 36,000 - 48,000; Full time

Job summary

Springfield Clinic is seeking a Medical Practice Scribe to document physician services in real time during patient encounters. You will enter dictated information into the EHR, retrieve related data, and ensure accurate, timely notes while maintaining HIPAA compliance.

Responsibilities include accompanying physicians during visits, recording diagnoses and discharge instructions, and performing clerical duties as needed.

Qualifications

• High School graduate or GED required.
• Completion of a medical terminology course is preferred, or previous medical terminology experience in a clinical setting.

Responsibilities

• Accompany the physician during a complete visit encounter and document in real time the words, actions, physical examination findings, procedures and treatments as performed by the physician.
• Accurately enter information into the EHR as dictated by the physician and document the physician's actions and words during the visit.
• Retrieve data for physician review such as labs, radiology reports and medical records.
• Record physician-dictated diagnoses, prescriptions and discharge/follow-up instructions.
• Will not touch patients or perform clinical tasks.
• Adhere to the SOPs for Scribe usage in the Medical Office.
• Perform other clerical duties as assigned by the operations manager, physicians and/or advanced practitioner.
• Comply with incident reporting policies and procedures; adhere to OSHA requirements.
• Provide excellent customer service and follow the clinic's service philosophy.
• Perform other job duties as assigned.

Skills

Typing 80-90 wpm

Multi-tasking

Professional communication

Education

High School diploma or GED

Medical terminology course (preferred)

Tools

EHR system

Job description

Job Description

The Medical Practice Scribe is responsible for functioning as a real time documenter of the physician services performed during a patient encounter in the medical practice environment. Responsible for accurately entering information into the EHR as dictated to them by the provider.

Job Relationships

Reports to the Operations Manager

Principal Responsibilities

• Accompany the physician during a complete visit encounter and document in real time the words, actions, physical examination findings, procedures and treatments as performed by the physician.
• Accurately enter information into the EHR as dictated to them by the physician. Document the physician's actions and words during the visit while in the presence of the physician. Enter the information into the EHR under his/her own log-in.
• Retrieve data for physician review such as labs, radiology reports and medical records. May transcribe a provider's consultations with other healthcare professionals, patients and family members.
• Record physician-dictated diagnoses, prescriptions and instructions for patient discharge and/or follow up.
• Will not touch patients or perform any clinical tasks.
• Must fully understand and adhere to the standard operating policies and procedures specific to ""Scribe: Guidelines for Use in the Medical Office.""
• Perform other clerical duties as assigned by operations manager, physicians and/or advanced practitioner.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to SC Way customer service philosophy.
• Perform other job duties as assigned.
• Education/Experience
• High School graduate or GED required.
• Completion of a medical terminology course is preferred, or previous medical terminology experience in a clinical setting.

Knowledge, Skills And Abilities

• Ability to multi-task and consistently communicate in a professional manner.
• Excellent typing and language skills. Typing proficiency of 80-90 wpm.

Working Environment

• Normal office setting.
• Minimal lifting requirements.
• 50% sitting, 50% standing.

PHI/Privacy Level

HIPAA1