Clinical Scribe - Non-Certified

Reviews vital signs and general information in patient chart. Accompanies provider(s) into patient examination room to accurately and efficiently document the encounter including HPI, physical exam, and assessment and plan as presented by provider. Document lab and radiology findings. Document procedures, consults, and discussions. Enter and pend orders for provider signature. Locate past medical history, previous notes, and recent studies at the provider's request. Maintains patient health record in an up-to-date status especially in regard to pain assessment, problem list, quality measures, and current medication sheet. Assures documentation is complete, concise and correct. Contributes to plan of care for individuals and groups of patients utilizing all principles to reduce medication errors when handling or calling in medications or refills. Enters accurate and concise data into the EMR. Answers phones, routes calls and or takes accurate message. Processes patient referrals for tests and referral to specialists per clinic workflow. Maintains record of referrals and/or logs or demonstrates correct use of tracking and alarm monitors in the Athena clinical EMR system. Assists nursing and or other clinic personnel in follow up to ensure patient compliance, receipt of test results and reports from specialist.

Education/formal Training/licensure/certifications/experience

Experience working in a medical related field where medical terminology and electronic medical records are in use. Medical background experience preferred. Writing skills, knowledge and demonstration of proper grammar and spelling in documentation, accurate and efficient typing speed, ability to respond to and anticipate needs of provider and patient, skilled at operating computers and troubleshooting when necessary, ability to use and understand documents required throughout execution of duties, ability to maintain and adjust to changing needs of provider(s) ability to work independently as well as with a team, strong interpersonal and verbal communications skills, ability to perform several tasks at one time and react calmly and effectively in an emergency situation.