Oncology Medical Scribe - Real-Time EHR Documentation

American Oncology Network; Houston (TX); On-site; USD 20,000 - 32,000; Full time

Job summary

Oncology Consultants in Houston is seeking a medical scribe to accompany the physician into the exam room and document each patient’s interaction using real-time EHR dictation. This role is clerical and not a patient care provider.

Responsibilities include charting patient encounters with history, exams, findings, treatments and instructions, presenting the medical record for physician review, and ensuring confidentiality and compliance with all laws and policies.

Qualifications

• One year in healthcare field required; direct patient care experience preferred.
• Strong knowledge of medical terminology.
• High school diploma or GED required.
• Valid driver’s license required for travel between clinics.

Responsibilities

• Accompany the physician in the exam room for the patient interview and examination.
• Demonstrate the knowledge and skills necessary to document patient care as dictated by the physician in a legible, clear manner following all local, state and federal guidelines for documentation.
• Accurately and timely charting of patient encounters, including but not limited to patient history, physical exams, diagnostic findings, treatment courses, diagnoses, prescriptions and instructions as provided by the physician.
• Complete and present the medical record with logical note flow using the Electronic Health Record (EHR) system for review by the physician for any amendments before the physician signs the chart.
• Make chart rounds with the physician to review patient status, delays and any other care-related issues.
• Refer all requests related to patient care to the physician or nursing staff.
• Interact with all co-workers, physicians, patients and others in a positive manner to illustrate AON as helpful and encouraging to both internal and external customers.
• Comply with all Federal and State laws and regulations pertaining to patient care, patients’ rights, safety, billing, human resources and collections.
• Adhere to all FCS and departmental policies and procedures, including IT policies and procedures and Disaster Recovery Plan.
• Keep work area and records in a neat and orderly manner.
• Maintain all company equipment in a safe and working order.
• Maintain and ensure the confidentiality of all patient and employee information at all times.
• Will be expected to work at any AON location to help meet AON business needs.
• Will be expected to work overtime when given sufficient notice of required overtime.

Skills

Medical terminology

Healthcare field

Education

High school diploma or GED

Tools

EHR system

Job description

Oncology Consultants in Houston is seeking a medical scribe to accompany the physician into the exam room and document each patient’s interaction using real-time EHR dictation. This role is clerical and not a patient care provider.

Responsibilities include charting patient encounters with history, exams, findings, treatments and instructions, presenting the medical record for physician review, and ensuring confidentiality and compliance with all laws and policies.