This paragraph summarizes the general nature, level and purpose of the job.
Service Area: Pediatric Otolaryngology (ENT)
Under the direction of a physician, the Medical Scribe assists with a variety of critical tasks that allow physicians to spend less time on the computer and more time with their patients.
One of the key tasks a medical scribe performs is performing documentation in the Electronic Health Record (EHR). The focus of the job is to enhance the efficiency and improve the throughput of patients while maintaining and improving patient satisfaction. The medical scribe will accomplish this in the following manner:
- Document the H&P and course for each pt
- Documentation of the following but not limited to: HPI, ROS, PMH, FSHx, allergies, MDM, DDx, Dx
- Record and track lab, imaging, and EKG findings and results
- Document procedures, consults, discussions, etc.
- Record verbal provider notes
- Prepare patient instructions
- Track pending orders
- Research PMHx, previous H&Ps, and studies
- Place phone calls or pages
- Prepare work or school notes
- Communicate with clinic staff
- Perform a variety of non-clinical provider requests
- Improve the efficiency of patient care by assisting the physician with routine matters.
- Serve as an ambassador/liaison between the physician, the patient in the clinic setting
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient’s rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
- At the physician’s discretion, the scribe shall accompany the supervising physician during a patient’s history taking and examination.
- The scribe will record onto the electronic medical record (EMR) the details of the patient’s visit as directed by the physician. The physician may elect to personally document any part of any patient’s record, or to complete it in its entirety.
- After the scribe and the physician leave a patient’s room, the physician will review the documentation entries recorded by the scribe during the encounter, and will make any and all necessary amendments to the patient’s medical record so that it is accurate and complete. The physician retains exclusive responsibility for the documentation of all patient care information recorded by the scribe during each patient encounter and at all other times.
- The scribe can assist the physician with researching and recording a patient’s PMH by assembling and reviewing nurse’s notes, EMS reports, referral notes from other health care facilities, and hospital records (e.g., prior admission notes, discharge summaries, operative/procedure notes and other records).
- At end of the physician documentation, beneath the signature lines, the medical scribe will electronically Esign the record in addition to the physician’s signature.
Secondary Duties (Occasional)
- The scribe may advise the physician when test results are available, when a patient is ready for disposition (i.e., all tests are resulted), when a critical value has been flagged/reported, when a patient is ready for a procedure (i.e., the appropriate cart is in the room and ready for use), and when there has been a delay in completion of ordered tests (e.g., a urine has not been obtained, blood has not yet been drawn, etc.).
- The scribe may perform a “patient ambassador” function on behalf of the physician, checking to see if patients are comfortable, have had adequate pain relief, etc.
- The scribe may serve as a liaison between the physician and nurses, other support staff, and clinical associates by forwarding messages between the parties. The scribe may not communicate messages regarding direct patient care (e.g., medication or IV orders).
- The scribe may also perform the above functions in collaboration or in support of the resident working with the physician.
- The physician will personally enter all orders for patient care utilizing EPIC. Scribes will not enter such orders.
- All medication and nursing orders for patient care are to be personally communicated to a nurse directly by the physician, and not by a scribe.
- The physician will sign each patient’s medical record when it is complete and after he/she has reviewed and, if necessary, amended the document for accuracy.
Education: High School Diploma and/or GED equivalent
Experience: Three (3) years of overall related experience. Preferred previous experience as medical scribe in ambulatory setting or experience in a healthcare educational program. Otolaryngology experience preferred.
License/Certification: Current Basic Life Support Certification (from American Heart Association).
Knowledge, Skills, and Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
- Successfully complete any designated Training and Orientation Programs.
- Attend any required new-employee orientation sessions, complete all HIPAA/Compliance training and background/exclusion checks required, receive any vaccinations required, and sign all applicable confidentiality agreements and forms.
- Must possess significant medical terminology knowledge and medical thought process background.
- Demonstrated business communication skills, including the ability to write and type clearly and legibly (with solid knowledge of grammar and spelling).
- Ability to demonstrate computer knowledge and understanding of Microsoft Office applications (Word, Excel, PowerPoint, Outlook).
- Have the ability to interact pleasantly, cooperatively, and respectfully with patients, families, physicians and Emergency Department staff.
- Possess the ability to work effectively and maintain poise under stressful conditions.
- Ability to demonstrate customer service skills.
- Knowledge and understanding of an electronic medical record system and/or EPIC.
- Upper level knowledge of medical terminology.
Physical Requirements and Working Conditions
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
- Be in good health, and be able to stand and record using a computer, clipboard, or other recording device for long periods of time.
- Required to wear approved scrubs. Must comply with dress code
- Be committed to reporting to work on time and being appropriately prepared at the beginning of each shift.