Scribe - Lead

Overview

PURPOSE STATEMENT: 

​Provide administrative support to facility Physician to ensure efficient dictation of patient notes and situations.  

Responsibilities

• Accompany the physician during examination of the patient. 
• Accurately document the physician dictated patient history, history of present illness, pertinent findings, mental status examination, medications and allergies.  
• Accurately document the results of laboratory and radiographic studies as dictated by the physician. Accurately document the diagnoses, procedures, risk factors, and plans as dictated by the physician.
• Uses the team approach to patient care and documentation. 
• Ensures all orders for patient care are communicated by the physician and not the Scribe.
• Complete and present the medical record in collaboration with the physician.
• Responsive to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician, ancillary hospital staff. 
• Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation. 
• Maintain confidentiality and privacy in accordance with governing HIPAA regulations.
• Treat all information, data and training materials utilized in the scope of the Scribe position with complete confidentiality and security. 
• Cooperates fully with all risk management activities and investigations. 
• Adheres to policies and procedures regarding medical terminology and approved abbreviations. 

Qualifications

​EDUCATION/EXPERIENCE/SKILL REQUIREMENTS: 

• ​High school diploma or equivalent required.    

• ​One or more years’ administrative/scribe experience required.  

• ​Knowledge of administrative and clerical procedures and systems such as managing files and records.  

We are committed to providing equal  employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.