- Works to facilitate patient flow and ensure an accurate and complete medical record for each patient.
- Assists the provider with all clerical activities related to the Electronic Health Record (EHR) to help support workflow and documentation for medical record coding.
- Ensures good teamwork and effective interpersonal relationships.
- Works to improve Press-Ganey patient satisfaction scores.
- Works effectively and cooperatively with other members of the team.
- One year in a medical office, hospital or practice setting
- Medical Assistant or Certified Medical Transcriptionist or Certified Scribe
- High School Graduate
- Computer proficiency and understanding of the functions of an electronic medical record.
- Proficient with medical terminology and technical spelling
- Bachelors Degree. Successful completion of Medical Assistant training program.
- Healthcare student - physician, nursing, physician assistant, healthcare administration.
- College level education including health or medical related courses or athletic trainer.
- Completion of a medical terminology course or one year medical terminology experience in a clinical setting.
- Experience with dictation systems and transcription
- Excellent and legible penmanship.
- Ability to multi-task and consistently communicate in a professional manner and perform duties under pressure.
- Ability to handwrite or key into EHR large amounts of dictated information.
- Adequate knowledge of computer usage and ability to tolerate viewing on computer monitors for extended periods of time.
- Upper level knowledge of medical terminology. Upper level typing/computer skills.
- American College of Clinical Information Managers (ACCIM) Certification (MSCAT) preferred or completed within 1 year.
- The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR c)
Medical Scribe - Portsmouth, United States - Wentworth-Douglass Hospital(WDH)
Description
At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives.
Medical scribes duties include performing all clerical and information technology functions for and under the direction of a provider in a practice/setting.
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.
Accompanies provider into the patient examination room in order to transcribe a history and physical exam, and document accurately the provider's encounter with the patient and others present following established guidelines for documentation.
b. Lists all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.c.
Scribes document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies during the visit exam.
d. Documents all procedures performed by the physician.e. Scribes document physical examination findings and procedures as performed by the physician.
f.
Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
g. Scribes may que up orders for the physician to authenticate and initiate. All orders for patient care must be communicated by the physician and not the scribe.h.
Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to transporting specimens, answering phones, assisting patients, calling physicians, etc.
a. Responds to various messages as directed by the provider.
b. Researches information requested by the provider.
c. Prepares referral letters as directed by the physician.
d. Assists provider with obtaining or locating information in Soarian, or other EHR systems as appropriate.
a. Recognizes sensitive situations and seeks appropriate assistance.
b. Monitors personal work ethic, behaviors and attitude.
c. Recommends improvement in orientation/work environment.
d. Maintains strong and effective relationships with peers, staff, physicians, agencies, and other organizations consistent with the hospital's strategic plan.
a. Actively participates in recommending plans of action to address any identified issues.
b. Participate in any OE or project related initiative
c. Mentor new scribe employees on policy and procedure as needed.
Qualifications
Experience Minimum Required
Experience Preferred/Desired
Education Minimum Required
Education Preferred/Desired
Training Minimum Required
Training Preferred/Desired
Special Skills Minimum Required
Special Skills Preferred/Desired
Licensure and/or Certifications Required
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.