Medical Scribe | Round Rock Rehab
2 months ago
The Medical Scribe is responsible for performing all clerical and information technology functions for physicians. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. The incumbent must be able to anticipate physician needs, must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. This position requires great attention to detail and must be reliable. This is a non-exempt position.
RESPONSIBILITIES
• Documents or records the visit elements exactly as stated by the practitioner without interjecting his or her own observations or impressions
• Captures accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner
• Assists the practitioner in navigating the medical record
• Responds to various messages as directed by the practitioner
• Locates information for review (previous notes, reports, test results, and lab results)
• Documents information into the medical record as directed by the practitioner
• Enters information in the electronic health record such as patient history, system review and physical examination, vital signs, procedures and treatments performed by the practitioner, care plan and medication lists, progress of lab, x-ray or other patient evaluation data, and practitioner dictated diagnoses, prescriptions and instructions
• Researches information requested by the practitioner
• Must make entries in the electronic health record using their own password/access for all entries and must clearly include the name of the scribe and a legible signature/electronic signature, the name of the practitioner rendering services, qualifications of each person, and authentication of the scribe, including accurate date and time of service
• Supports practitioner in care documentation and data retrieval
• Performs other duties as assigned to meet the organization’s needs
QUALIFICATIONS
Education and Training: High school graduate, enrolled in college courses is required. Bachelor’s degree is preferred in Science or Healthcare related field.
Experience: Required: 1 year experience working in a similar position
Preferred: 2 years’ experience in a similar position or clinic setting
Knowledge, Skills, and Abilities:
• Knowledge of medical terminology
• Knowledge of EHR programs and Windows environment
• Must possess excellent attention to detail
• Must be self-motivated and versatile to handle many tasks
ABOUT US
PAM HEALTH(PAM) based inEnola, Pennsylvania, provides specialty healthcare services through more than 70 long-term acute care hospitals and physical medicine and rehabilitation hospitals, as well as wound clinics and outpatient physical therapy locations, in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service, coupled with the loyalty and dedication of highly trained staff, to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate, expert care, and to support recovery through education and research.
Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.
We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online atwww.PAMHealth.com for a comprehensive look at how we're able to positively impact our local communities.
PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.
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