Real-Time Medical Scribe & EHR Entry Specialist

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

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.