JOB SUMMARY: A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of the physician or practitioner. The scribe does not and may not act independently but can document the previously determined physicians or practitioner’s dictation and/or activities.

DUTIES & RESPONSIBILITIES:

1. Accompany physician into the patient examination room in order to transcribe all of the procedures and interactions the doctor has with the patient and any others present.

2. List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.

3. May be responsible for generating referral letters for physicians, manage and sort medical documents within the EMR system, and assist with e-prescribing.

4. May be responsible for ordering labs and other types of studies as ordered by the doctor.

5. Transcribe patient orders including laboratory tests, radiology tests, medications, etc.

6. Will attend OSHA training upon hire and annually thereafter.

7. Establish and maintain effective working relationships with providers, staff and management.

8. Attends all required in-service programs and employee informational meetings as designated by Supervisor.

9. Practices time management, keeping authorized break periods within accepted policy. Maintains level of productivity as established for the department.

10. Complies with established SDMG attendance policy.

11. Provides proper notification for absences and scheduled time-off in accordance with SDMG policy.

12. Complies with SDMG policies and procedures pertaining to Incident Reporting and promptly notifies Supervisor of all incidents.

13. Knowledgeable of individual responsibilities and duties pertaining to SDMG safety/emergency preparedness including emergency codes.

14. Demonstrates a knowledge of proper body mechanics to be used in the work setting.

15. May be exposed to hazardous drugs.

16. Attends OSHA training upon initial employee orientation and annually completes an OSHA competency.

RELATIONSHIP WITH OTHERS: Deals with physicians of the Group in relation to the transcription function. Must have ability to deal effectively and courteously with fellow employees, staff, physicians, and administration.

EDUCATION/EXPERIENCE/KNOWLEDGE: Graduated from High School or completed GED requirements; 6 months experience as a Medical Scribe preferred; 6 months related experience and/or training, or equivalent combination of education & experience; Must have excellent spelling and punctuation; Ability to type 60 words a minute; Must maintain confidentiality of patient records, and maintain effective work relationships with peers and supervisor.

PHYSICAL REQUIREMENTS: Classification of work level: Light. Requires sitting, standing, bending and reaching. May require lifting up to 10 pounds using proper body mechanics. Requires manual dexterity to operate standard office equipment such as computer, fax and telephone. Requires hearing and vision that is adequate to perform job duties.