Scribe - Orthopedics - FT

McLeod Health; Little River (SC); On-site; USD 19,000 - 25,000; Full time

Job summary

McLeod Health in Little River, South Carolina is seeking a Medical Scribe to document patient encounters under physician supervision. You will record progress notes, history of present illness, exam findings, and procedures as verbalized by the clinician, without adding personal interpretations.

This role focuses on clerical transcription of provider-patient communications, following established scribing policies and CMS guidelines.

Qualifications

• Three (3) years office experience in a position dealing with the public.
• Post high school training in medical terminology preferred.

Responsibilities

• Record accurate patient progress notes verbalized by the physician’s interaction with the patient.
• Transcribe verbal communications between provider and patient; perform scribe tasks only after physician enters exam room.
• Review and comply with McLeod Health scribing policies and CMS guidelines.
• Perform other duties as assigned by the practice manager.

Skills

Office experience

Customer service

Education

High School/GED

Medical terminology training

Job description

Job Description

• The medical scribe is responsible for recording accurate patient progress notes verbalized by the physician’s interaction with the patient relevant to the chart. Progress notes may include history of present illness, physical exam findings, medical decision making, laboratory results, radiology findings, consultations and dispositions. The medical scribe does not interject his or her own opinions, impressions and does not interpret clinical information.
• The medical scribe is a clerical related task whereby a trained medical professional transcribes verbal communications between the provider and the patient. The medical scribe may only perform scribe related tasks, once the physician enters the exam room. The scribe role is 100% scribe and is not to be asked to perform other duties such as injections, obtaining vitals, and authorizations.
• The medical scribe is required to review and comply with the Scribing policies and procedures defined by McLeod Health adhering to all policies and procedures at all times. The scribe, along with the provider, will acknowledge that he/she understands their responsibility as set forth by the policy.
• The scribe and provider will insert specific documentation, as outlined by the scribe policies and procedures, to acknowledge the patient information was transcribed by a scribe. The scribe and the provider will capture this documentation at the time of service in order to remain compliant with CMS guidelines.
• Performs all other duties as assigned by the practice manager.

Responsibilities

• The medical scribe is responsible for recording accurate patient progress notes verbalized by the physician’s interaction with the patient relevant to the chart. Progress notes may include history of present illness, physical exam findings, medical decision making, laboratory results, radiology findings, consultations and dispositions. The medical scribe does not interject his or her own opinions, impressions and does not interpret clinical information.
• The medical scribe is a clerical related task whereby a trained medical professional transcribes verbal communications between the provider and the patient. The medical scribe may only perform scribe related tasks, once the physician enters the exam room. The scribe role is 100% scribe and is not to be asked to perform other duties such as injections, obtaining vitals, and authorizations.
• The medical scribe is required to review and comply with the Scribing policies and procedures defined by McLeod Health adhering to all policies and procedures at all times. The scribe, along with the provider, will acknowledge that he/she understands their responsibility as set forth by the policy.
• The scribe and provider will insert specific documentation, as outlined by the scribe policies and procedures, to acknowledge the patient information was transcribed by a scribe. The scribe and the provider will capture this documentation at the time of service in order to remain compliant with CMS guidelines.
• Performs all other duties as assigned by the practice manager.

Qualifications

• Three (3) years office experience in a position dealing with the public.
• Post high school training in medical terminology preferred.

Requirements

Degrees

High School/Ged

Memberships

Occupation Risk Assessment

About Us

Founded in 1906, McLeod Health is a locally owned and managed, not for profit organization supported by the strength of more than 900 members on its medical staff and more than 2,900 licensed nurses. McLeod Health is also composed of approximately 15,000 team members and more than 90 physician practices throughout its 18-county service area . With seven hospitals, McLeod Health operates three Health and Fitness Centers, a Sports Medicine and Outpatient Rehabilitation Center, Hospice and Home Health Services. The system currently has 988 licensed beds , including Hospice and Behavioral Health. The hospitals within McLeod Health include: McLeod Regional Medical Center, McLeod Health Dillon, McLeod Health Loris, McLeod Health Seacoast, McLeod Health Cheraw, McLeod Health Clarendon and McLeod Behavioral Health.

About The Team

If you would enjoy working in a dynamic environment and are looking for an opportunity to become part of a stellar team of professionals, We are an equal opportunity employer.