What are the responsibilities and job description for the Medical Scribe position at ARcare?
POSITION SUMMARY
The purpose of this position is to handle time-consuming clerical responsibilities for providers. Scribes accurately document the events and decision-making in a manner that results in appropriate medical charting. By accomplishing the clerical duties that otherwise would be assigned to a provider, scribes enable providers to spend more time with individual patients and increase the overall flow of patients in the clinical setting.
ESSENTIAL FUNCTIONS
Reasonable Accommodations Statement : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
Essential Functions Statement(s)
- Performs documentation under their own log in credentials (not under the log in credentials of a provider).
- Accompanies the provider into the patient exam room to transcribe.
- Documents the provider-dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
- Documents the physical examination findings and procedures as performed by the provider, and plan.
- Documents the results of laboratory and radiographic studies as dictated by the provider
- Documents all proper diagnoses and symptoms as well as follow up instructions as dictated by the provider.
- Documents orders within the scope of practice allowed by state law. The provider should be nearby when this is occurring so they can react to rules and alerts. Scribes reacting to best practice alerts intended for providers is not acceptable.
- Does not accept or give verbal orders.
- Does not provide scribe services to a provider without a signed agreement.
- Adheres to all policies and procedures, including but not limited to standards for safety, information security, infection control, attendance, punctuality, and personal appearance.
- Performs other necessary duties as required by the Center to meet the goal of providing primary health care services
SKILLS & ABILITIES
Education: Minimum High School Equivalent
Experience: Experience in a medical field with computer skills is preferred but not required.
Computer Skills: Ability to navigate current Electronic Medical Record
Other Requirements
- Maintain and demonstrate an understanding of the team approach to patient care and documentation
- Complete and present the medical record in collaboration with the supervising provider
- Communicate in a professional and respectful manner to the supervising provider
Understanding of medical terminology
