Medical Scribe

Trinetic Healthcare

Full Time
Dallas, TX
Posted 2 weeks ago

Job Description:

Medical Scribes are individuals trained in medical documentation who assist a
physician throughout their shift. The primary goal of a Medical Scribe is to
increase the efficiency and the productivity of the physician they are working
for. The Medical Scribe allows the doctor to focus on what is most important,
the patient.

A summary of a Medical Scribes duties include performing all clerical and
information technology functions for a physician in a clinic setting. This
includes primary responsibility of the operation of the electronic health
records and electronic dictation system. You also must be able anticipate
physician needs to facilitate the flow of clinic. Medical Scribes must be
discreet, tactful, and modest in performance of duties so as not to distract
medical staff from patient care. Good judgment, organizational ability,
initiative, attention to detail, and the ability to be self-motivated are
especially important when working as a Medical Scribe. You must be adaptable
and versatile since you will be responsible for many tasks. Good attendance is
also an important element of this job since you will be hard to replace.

Some of the more detailed job duties and responsibilities of a Medical Scribe
are:

Accurately and thoroughly document medical visits and procedures as they are
being performed by the physician, including but not limited to:

* Patient medical history and physical exam,
* Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
* Patient education and explanations of risks and benefits.
* Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
* Prepare referral letters as directed by the physician

Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to
prepare referral letters as directed by the physician, via dictation or
summary of the medical record. Medical Scribe also ensure that letters are
mailed or faxed on a daily basis to all physicians involved in a patient’s
care, and with all copies of pertinent reports or tests attached. You may be
asked to research contact information for referring physicians, coordinate
referrals, prepare operative reports, make phone calls, and other clerical
tasks as assigned.

Medical Scribes also spot mistakes or inconsistencies in medical documentation
and check to correct the information in order to reduce errors. All addenda
must be signed off by a physician. Medical Scribes ensure that all clinical
data, lab or other test results, the interpretation of the results by the
physician are recorded accurately in the medical record. Alert physician when
chart is incomplete. Medical Scribes must comply with specific standards that
apply to the style of medical records and to the legal and ethical
requirements for preparing medical documents and for keeping patient
information confidential.

Medical Scribes collect, organize and catalog data for physician quality
reporting system and other quality improvement efforts and format for
submission. You will assist in developing and maintaining systems to track
patient follow up and compliance.

Attend trainings on diverse subjects such as information technology, legal,
HIPAA and regulatory compliance, billing and coding. Quickly assimilate new
knowledge into processes and procedures. Medical Scribes proofread and edit
all the physician’s medical documents for accuracy, spelling, punctuation, and
grammar.

Qualifications:

To perform this job successfully, an individual must be able to perform each
essential duty satisfactorily. The requirements listed below are
representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform
the essential functions.

Language Skills – The ability to write routine reports and
correspondence. Medical Scribes must be proficient in typing and good at
spelling, punctuation, grammar, and oral communication. Must be able to listen
to complex medical information and summarize in a clear, complete, and concise
fashion. Excellent English composition skills required to generate
professional, polished writing at a high rate of production. Handwriting must
be clear and legible.

Understanding of medical terminology, anatomy and physiology, diagnostic
procedures, pharmacology, and treatment assessments to the extent required
to understand and accurately transcribe dictated reports. Translate medical
abbreviations into their expanded forms.

Mathematical Skills – Ability to add, subtract, multiply, and divide in
all units of measure, using whole numbers, common fractions, and decimals.
Prepare and interpret charts and graphs. Have the ability to compute ratio and
percent.

Reasoning Ability – Ability to apply common sense understanding to carry
out instructions furnished in written, oral, or diagram form. Ability to apply
logic and draw conclusions based on knowledge. Have the ability to refer to
reference materials to solve problems.

Computer Skills – To perform this job successfully, an individual should
be able to learn and use all functions of electronic medical record software
and transcription software. Must accurately enter data into a database, search
for information, send and receive email and attachments. Must be proficient in
Microsoft Word in order to prepare correspondence, medical reports, and other
documents. Must use Microsoft Excel to prepare flowcharts and organize data.
Must use the internet to access schedules, research information, etc.

Other Skills and Abilities – Must be able to type words and numbers
quickly and accurately; must comply with HIPAA confidentiality standards
when accessing or communicating patient information.

Job Features

Job CategoryOther