Medical Scribe - Newton, United States - Partners Healthcare System

Description

• External

Medical scribe's duties include performing all clerical and information technology functions for and under the direction of a provider in a practice/setting.

This includes primary responsibility of the operation of the electronic health records (EHR) and electronic dictation system. Ability to anticipate physician needs to facilitate the flow of clinic.

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.

• Works to facilitate patient flow and ensure an accurate and complete medical record for each patient. a. 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.
• Assists the provider with all clerical activities related to the Electronic Health Record (EHR) to help support workflow and documentation for medical record coding. Assists provider in navigating the EMR and locating information such as tests, lab results, and hospital dictation. a. Responds to various messages as directed by the provider. b. Research 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.
• Ensures good teamwork and effective interpersonal relationships. Communicates effectively and handles confidential matters per policy and procedures. 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.
• Works effectively and cooperatively with other members of the team. Identify opportunities for improving processes related to quality initiatives. a. Actively participates in recommending plans of action to address any identified issues. b. Participate in any OE or project related initiatives c. Mentor new scribe employees on policy and procedure as needed.
• Clean and sterilizes equipment, instruments, including scopes and documents on daily log sheets per MEEI policy standards. Set up and clean exam room and procedure rooms according to infection control standards. Bring patients back to exam room, review patient history, document allergies, complete medication reconciliation and ensure all information is properly documented in electronic medical record.
• High School Graduate
• Computer proficiency and understanding of the functions of an electronic medical record.
• Proficient with medical terminology and technical spelling

Special Skills Minimum Required

• 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.
• Ability to type a minimum of 60 words per minute.

Special Skills Preferred/Desired

• Upper-level knowledge of medical terminology. Upper-level typing/computer skills.