Medical Scribe - No Experience Needed - N.A. - (Bel Air, MD)
A Scribe is trained to relieve the provider of clerical duties; thus allowing the provider to focus more directly on clinical care. A Scribe’s role is limited to documentation and efficiency management for the provider. The Scribe is an unlicensed person and exclusively non-clinical. The Scribe does not touch patients and does not engage in any type of patient care. The Scribe observes the provider during patient encounters and performs documentation on the provider’s behalf. Under the direction of the provider, the Scribe enters information into the patient’s electronic or written chart. All documentation is reviewed and/or edited by the provider. It is signed with an attestation by the provider that the scribed chart accurately reflects all work performed by the provider. Duties and ResponsibilitiesChart in real-time as the provider assesses and examines the patient Document the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultations Record provider-dictated diagnoses, prescriptions and instructions for patient follow-up Locate and obtain past medical histories, previous charts, past results and studies Transcribe ancillary test results and their interpretations Check on the progress of labs, imaging studies, and other patient data Retrieve and display current and past EKGs and imaging films (e.g. X-rays) for the provider to review and record provider’s interpretation Understand basic ICD-10 documentation requirements Comply with all national and local PHI laws including in HIPAA and HITECH Comply with all facility, department, company policies and procedures Perform a variety of other non-clinical tasks specific to the local facility This position requires:High school diploma or the equivalent Exemplary work ethic and professionalism Excellent verbal and written communications skills Ability to adapt to individual site needs Strong computer skills – technological savvy A typing …
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