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Medical Scribe
4 months ago
Department:
02050 AMG Westhaven - CardiologyStatus:
Full timeBenefits Eligible:
YesHou rs Per Week:
40Schedule Details/Additional Information:
Monday - Friday, typically 8am - 5pm.
Includes some travel to Fond Du Lac roughly 2 times per month.
Major Responsibilities:
In accordance with policy, prepares and assembles medical record documentation/chart for physician prior to patient visit. Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results. Ensures that all elements of documentation are complete and accurate. Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications. Documents the physician/clinician's communication with the patient using appropriate medical terms and phrasing. Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders. Documents the correct follow-up instructions and level of service designation based on the physician/clinician's direction. Assists in data entry from devices or other sources. Completes medical records for each encounter ensuring accurate and timely documentation. Under physician/clinician direction, updates patient history and other pertinent health information in the patient record. Prepares and sends all documentation for review and approval. With proven competency, may perform clinical functions such as prepare and room patient for exam, obtain vital signs and document/update pertinent health information, assist the physician/clinician with non-sterile procedures, schedule appointments and referrals to other facilities or services, and perform other data entry into the EHR.
Licensure, Registration, and/or Certification Required:
Education Required:
Experience Required:
Knowledge, Skills & Abilities Required:
Physical Requirements and Working Conditions: