Medical Scribe

**When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.**

**Job Type**:
Regular

**Scheduled Hours**:
40

**Work Shift**:
Day (United States of America)

The Scribe observes the provider (either virtually or in-person) during patient encounters and performs documentation on the provider’s behalf. Under the direction of the provider, the Scribe enters information into the patient’s electronic or written chart. All documentation is reviewed and/or edited by the provider. It is signed with an attestation by the provider that the scribed chart accurately reflects all work performed by the provider. A Scribe is trained to relieve the provider of clerical duties; thus allowing the provider to focus more directly on clinical care. A Scribe’s role is limited to documentation and efficiency management for the provider. The Scribe is an unlicensed person and exclusively non-clinical. The Scribe does not touch patients and does not engage in any type of patient care.

**Essential Duties & Responsibilities including but not limited to**:
1. Chart in real-time as the provider assesses and examines the patient
2. Document the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultations
3. Record provider-dictated diagnoses, prescriptions and instructions for patient follow-up
4. Locate and obtain past medical histories, previous charts, past results and studies
5. Transcribe ancillary test results and their interpretations
6. Check on the progress of labs, imaging studies, and other patient data
7. Retrieve and display current and past EKGs and imaging films (e.g. X-rays) for the provider to review and record provider’s interpretation
8. Understand basic ICD-10 documentation requirements
9. Comply with all national and local PHI laws including in HIPAA and HITECH
10. Comply with all Lahey Health and departmental policies and procedures

**Minimum Qualifications**:
Education: Determined by vendor

Licensure, Certification, Registration: Determined and monitored by vendor

Skills, Knowledge & Abilities: Determined by vendor

Experience: Determined by vendor

**FLSA Status**:
Non-Exempt

**As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. **Learn more** about this requirement.**:
**More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.**:
**Equal Opportunity Employer/Veterans/Disabled**: