Must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.Ĥ. Alert physician when chart is incomplete. Must ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. All addenda must be signed off by a physician. May spot mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors. May research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.ģ. Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.Ģ. Patient education and explanations of risks and benefits ĭ. Procedures and treatments performed by healthcare providers, including physician and physician assistants Ĭ. Patient medical history and physical exam ī. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.ġ.Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:Ī. The Medical Scribe must be able anticipate physician needs to facilitate the flow of clinic, while being discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. This includes primary responsibility of the operation of the electronic health records. The primary goal is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe performs all clerical and information technology functions for a physician in a clinic setting. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.ĬOO, Clinical Manager, Lead Medical Scribe or other designated individual Preferred: Familiarity with medical terminology.Įmployment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Assist with other office functions as needed. Generate referral letters for physicians. Manage and sort medical documents in the EMR system. Reviews documentation to determine accuracy. Follows physicians through his or her workday and chart patient encounters in real-time using a medical office's Electronic Health Record and existing templates.Ĭhart patient encounters in real-time during office visits.

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