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Healthcare Scribe

2 months ago

Tampa, Florida, United States Ladgov Corporation Full time
Job Overview

POSITION: Medical Scribes

LOCATION: MacDill AFB, Tampa, FL, United States

RESPONSIBILITIES:

  • Organizing and compiling medical documentation for healthcare providers.
  • Accompanying physicians during patient consultations to accurately record medical information using electronic health record systems.
  • Ensuring adherence to medical record standards through self-documentation verification, including scribe identification, physician details, and time-stamped entries.
  • Thoroughly documenting patient visits and medical procedures as they occur, including but not limited to:
  • Patient medical history and physical assessments.
  • Procedures and treatments administered by healthcare staff, including nurses and physician assistants.
  • Providing printed patient education materials and detailing risks and benefits.
  • Recording physician-directed diagnoses, prescriptions, and instructions for patient or family follow-up care.
  • Drafting referral letters as instructed by the physician.
  • Submitting all documentation for physician review and approval, ensuring accuracy and compliance with facility protocols.
  • Identifying and correcting discrepancies in medical records to minimize errors.
  • Maintaining a professional and organized workspace.
  • Accurately entering new patient data into electronic medical records.
  • Inputting orders into the electronic medical record (EMR) system.
  • Creating and modifying examination templates within the EMR for physician use.
  • Adhering to hospital/clinic policies and regulations, including HIPAA and Joint Commission standards.
  • Consistent and reliable attendance at the assigned facility is essential.
  • Performing additional clerical tasks to enhance provider efficiency and clinic operations as required.
  • Understanding and safeguarding confidential patient information is crucial.
  • This position may involve working at multiple clinics throughout the week.

EDUCATION & EXPERIENCE:

  • High school diploma or equivalent is required.
  • A minimum of three (3) years of experience in providing medical scribe services is preferred.
  • Proficiency in medical terminology and human anatomy is highly desirable.
  • Experience with various medical record software, word processing, and database applications is essential.
  • Excellent written and verbal communication skills with the ability to engage professionally within a diverse team environment.
  • Strong attention to detail and a solid work ethic in a dynamic setting.
  • Awareness of sensitive and confidential patient information is necessary.
  • Comfortable using technology and proficient in operating personal computers and relevant software.

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