Medical Scribe

US-FL-Land O'Lakes
# Positions
1
Category
Office and Administrative Support
Department
0211 CARDIOLOGY WESLEY CHAPEL
Job Status
Regular Full-Time
2100 Via Bella Blvd.

Job Description

Medical Scribe

Department:              Cardiology

Job Summary:           Provide an accurate and complete documentation of interactions between the medical provider and patient. 

Reports to:                 Office Supervisor

Position Level:           4A

 

Job Summary:           Provide an accurate and complete documentation of interactions between the medical provider and patient.      

                                   

Essential Functions of the Position:

  • Record details of chief complaint, history of present illness, review of systems, past medical history, social history, and disease risk factors.
    • Can be collected directly from patient and inputted into EHR.
  • Record details of the physical exam, including pertinent positives and negatives, noted abnormalities and patient’s general condition
    • This information is provided to the scribe for inclusion directly from the provider.
  • Document the assessment and plan as directed by the provider
  • Assist provider in submitting orders and follow up in obtaining results and findings of those orders
    • Follows provider’s directives when submitting orders and provides all information necessary for orders to be completed.
    • Gather laboratory results, radiology reports, and requested medical records for the provider to review.

 

Additional Responsibilities:

  • Maintains an organized and clean work area
  • Participates in maintenance of equipment required for completion of job duties.
  • Performs other incidental and related duties as required and assigned.
  • Scribes can answer the phone, if permitted by the provider.
  • Scribes can relay information from the provider but cannot give medical advice, or communicate medical information of care plans with the patient or the patient’s family as that is the provider’s responsibility.

 

Physical and Mental Demands:

  • Physical requirements
    • Able to stand or walk for long periods
    • Use of proper body mechanics
  • Normal concentration and normal complexity of decision making
  • High level verbal and written communication skills
  • Above average ability to manage multiple tasks simultaneously

  

Occupational Exposure:

  • Some risk exposure to bloodborne pathogens and chemical hazards
  • Repetitive motion work with keyboards

 

Job Qualifications:

  • High school graduate and one year of college
  • 1 year of medical scribe experience (or excellent typing skills) preferred
  • Working knowledge of medical terminology and accepted medical abbreviations
  • Recognition of physical exam process and ability to record exam details
  • Computer proficiency and ability to quickly learn new applications
  • Communication skills and the ability to coordinate and cooperate with multiple members of the healthcare team
  • Organizational skills with focus on tracking patient care and improving patient flow
  • Professional demeanor and recognition of privacy considerations for patients and families

 

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