Medical Record Technician

1 week ago

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

POSITION TITLE: Medical Scribes

LOCATION: Various Locations

RESPONSIBILITIES:

  • Organizing and compiling medical record documentation for healthcare providers.
  • Accompanying physicians during patient consultations to accurately capture and transcribe medical records using electronic health record systems.
  • Ensuring compliance with medical record standards through self-documentation, including scribe identification, physician details, and time stamps.
  • Thoroughly documenting patient visits and procedures as they occur, including:
    • Patient medical history and physical examinations.
    • Healthcare procedures and treatments administered by medical staff.
    • Patient education materials and explanations of potential risks and benefits.
    • Physician-dictated diagnoses, prescriptions, and instructions for patient care and follow-up.
    • Drafting referral letters as instructed by the physician.
  • Submitting all documentation to the physician for review and authentication, adhering to facility-specific protocols.
  • Identifying and correcting errors or inconsistencies in medical documentation to enhance accuracy.
  • 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 updating examination templates within the EMR for physician use.
  • Adhering to hospital/clinic policies, including HIPAA regulations and Joint Commission standards.
  • Consistent and reliable attendance at assigned facilities is essential.
  • Performing additional clerical tasks to support provider efficiency and clinic operations as required.
  • Understanding and commitment to safeguarding confidential patient information.
  • Willingness to work at multiple clinics as needed.

EDUCATION & QUALIFICATIONS:

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

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