Er Scribe Non Licensed - Full Time, Various Shifts

Overview

J ob Summary:

Assist the Emergency Medicine providers with documentation, transcription, and clerical functions to maintain an efficient workflow according to hospital policies and procedures.

Demonstrates through behavior Decatur Morgan Hospital’s mission, vision and values.

Responsibilities

Key Responsibilities / Essential Functions

• Practice proper infection control practices including adhering to current isolation precaution guidelines.
• Participate in departmental and/or hospital process improvement initiatives including annual hospital goals.
• Record details of the physical exam including pertinent positives and negatives, noted abnormalities, and patient general conditions as it is being performed and relayed by the provider.
• Capture all parts of patient care including things such as, but not limited to, critical care, end of life discussion, and smoking cessation counseling.
• Accompanying the emergency medicine provider to treatment space for patient evaluation.
• Assist with incomplete charts by reviewing delinquencies with the provider.
• Follow up on disposition of the patient for documentation including capturing discharge instructions, admissions, and/or prescription orders.
• Review previous visit records for important information including patients returning within 30 days of an inpatient discharge or returning within 72 hours of an ER discharge.
• Use two patient identifiers when discussing or documenting patient information.
• Monitor patient tracker board and notify provider of new arrivals.
• Record details of the chief complaint, history of present illness, review of symptoms, past medical history, social history, family medical history, disease risk factors, and any other patient information relevant to the presentation of the patient.
• Answer and field incoming calls to the provider lines in the emergency department.
• Act in a manner that is cordial and respectful to co-workers, patients, and patients’ families.
• Be sure that the provider reviews the documentation prior to the end of shift and make any edits necessary.
• Place calls to primary care providers, consultants, transfer centers, or other departments on be-half of the provider utilizing the hospital operator.
• Transcribe the results of tests, procedures, and/or imaging into the note after they are reviewed by the provider.
• Follow up on the status of diagnostic tests, procedures, and imaging and alert the provider to review.
• Use medical terminology and approved abbreviations in all medical record documentation.
• Complete annual HR and/or departmental requirements within specified time frame.

Prohibited Functions

• Providing any clinical care or advice to patients or families.
• Receive critical reports from diagnostic tests such as labs or imaging.
• Administer medications to patients or retrieve medications from supply rooms or pyxis machines.
• Touching or examining the patient.
• Enter orders on behalf of the provider or use provider’s PIN to sign notes.

Qualifications

Minimum Knowledge, Skills, Experience Required

Education: Minimum high school diploma or GED required. Associates degree or some college preferred. Completion of scribe training program.

Experience: Previous medical office or medical transcription experience preferred with knowledge of anatomy, physiology, and medical terminology.

Additional Skills / Abilities: Must have excellent communication skills with the ability to function in a fast-paced environment and change tasks frequently and quickly. Requires computer and typing skills with demonstrated knowledge in rules of grammar including spelling and punctuation.