Under the direction of the Medical Office Manager, the Medical Scribe is primarily responsible for the accurate electronic charting of patient history, patient-physician interactions and documenting notes based on the physician's dictation. The Medical Scribe acts as an assistant, accompanying the Physician during the examination and treatment of patients. Organizes healthcare data to provide better service and efficiency of clinical care.
- Accurately and thoroughly document patient-physician interactions as they are being performed by the physician, nurses or other healthcare professionals in the electronic medical record (EMR) for the patient. Transcribe physician dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up. Ensure that all clinical data, lab or other test results and the interpretation of the results by the physician are recorded accurately in the EMR. Audits patient charts and alerts Physician when chart is incomplete to assure appropriate and timely billing. Assists Physician in facilitating diagnostic tests and referrals to medical specialists. Maintain a clean and professional working environment. Adheres to HIPPA laws. Other duties as assigned by management.
- Excellent written, verbal and interpersonal communication skills. Associate degree and 2 – 4 years of related experience. Experience with EHR documentation. Technical proficiency with EMR and typing speed of 70+ wpm.
- Certification by the American College of Clinical Information Managers (ACCIM). 2+ years of EMR documentation with EPIC.
Pacific Dental Services is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military status.
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