- Preparing and assembling medical record documentation/charts for physician(s).
- Entering the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
- Ensuring medical record compliance by self-documentation attestation to include: Scribe name, title and doctor working for as well as specific date and time entry.
- 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.
- Printing and coding 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.
- Preparing and sending all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
- Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.
- Maintain a clean and professional working environment.
- Accurately enters new patient information in to electronic medical records file.
- Enters orders into the electronic medical record (EMR) system.
- Create and update exam templates in the EMR for the physician.
- Compliance with hospital/clinic and ProScribe policies, including those relating to HIPAA and Joint Commission.
- Regular and reliable attendance at assigned facility required.
- Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
- Understanding of and commitment to appropriate protection of confidential patient information.
- Position may require work at more than one clinic during a scheduled work week.
- High school diploma or equivalent.
- Candidate will have a minimum of three (3) years of providing medical scribe services as described herein.
- Ability to demonstrate knowledge of medical terminology and human anatomy strongly preferred.
- Skilled in operating various medical record software and hardware, word-processing, and database software programs.
- Strong written and verbal communication skills with the ability to communicate and interact professionally within a diverse team.
- Strong work ethic and attention to detail in a fast-paced work environment.
- Cognizance of delicate and confidential patient information.
- Tech-savvy and able to operate a personal computer and applicable software with ease.
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Medical Scribes - St Petersburg, United States - LADGOV CORPORATION
Description
JOB TITLE: Medical ScribesLOCATION: 3250 Zemke Ave, Tampa, FL 33621, United States
DUTIES:
