Company: PINEHURST MEDICAL CLINIC
Job Type: Permanent, FullTime
Medical Scribes assist physicians on a real-time basis with the clerical aspects of patient care. Clinically, a scribe remains “hands off.” Scribes allow the physician with whom they work to shift his/her focus off of their tablet PC or paper chart to their patient. The goal of a Medical Scribe is to effectively increase efficiency in the department and verify the patients' charts for accuracy and ensure that documentation meets appropriate coding requirements. This position will be split between Fayetteville and Sanford. Medical Assistant preferred.
Essential Functions and Responsibilities
- Assist the physician with documentation of each patient's medical record during his or her visit.
- Accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
- Transcribes any consultations or discussions with family members or other physicians about the patient's case.
- Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient's workup complete so that the physician is able to make his or her decisions regarding that patient.
- Lists all proper diagnoses as well as any follow-up instructions and prescriptions, as dictated by the physician.
- Ensure complete documentation through complete and accurate coding.
- Under the direction of the physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc.
- Performs other duties as assigned.
Education (Including Licenses and Certifications):
- High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
- Prior experience working as a medical scribe preferred.
- Excellent knowledge of medical terminology (meaning and spelling).
- Prior experience or knowledge of examinations, diagnostics, and treatment room procedures.
- Basic understanding of ICD-9 coding, CPT coding, and medical necessity as related to the ordering of laboratory work or procedures.