General Information
| Job Description | HOSP AST | Working Title | Medical Scribe (Per Diem) |
|---|---|---|---|
| Job Code | 008905 | Grade | |
| Department Name | SOM Neuroscience - D02016 | Department Head | Elizabeth Morrison-Banks |
| Supervisor | Effective Date | 02/06/2023 |
Position(s) Directly Supervised
| Job Code | Title | FTE |
|---|
Department Custom Scope
| The Medical Scribe (per diem) will perform duties that are directly related to the physical care of patients in an in-patient and/or out-patient facility. The primary responsibility is to listen and record confidential conversations between the provider and patients in the electronic medical record. As needed may assist with routine duties weigh and measure patients, collect and transport specimens, transport patients, assist in ambulating patients. May assist technical, nursing, and provider personnel in the care and treatment of patients under their specific direction. As requested, may administer procedures and treatments and may operate and maintain special equipment and medical devices. They will operate equipment such as the autoclave, make up sterile trays and packs. |
Education & Experience Requirements
Education Requirements
| Degree | Requirement |
|---|---|
| Degree in a healthcare related field. | Preferred |
Experience Requirements
| Experience | Requirement |
|---|---|
| Scribing or dictation in an outpatient clinic or inpatient setting. | Preferred |
| Skill in proofreading very detailed materials and monitor work accurately | Preferred |
| Detailed knowledge of medical terminology and the ability to distinguish different exams and medical diagnoses | Preferred |
| Prior experience with electronic medical records. | Preferred |
License Requirements
Certification Requirements
| Certification | Requirement |
|---|---|
| CPR/BLS certification. | Required |
Educational Condition Requirements
| Condition | Requirement |
|---|
Key Responsibilities
| Description | % Time |
|---|---|
| Prepares and assembles medical record documentation/charts for provider(s). Enters the patient room with the provider during patient visit to capture and transcribe medical record documentation utilizing electronic medical record application. Records patient care information, patient history, review of systems, physical exam findings, progress notes, and procedure notes. Review information with the provider at the completion of each documented outpatient visit to confirm accurate reporting. Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry. | 80 |
| Follow-up of laboratory and diagnostic results, expediting consults, and assisting with recording the documentation for patient care and follow-up | 10 |
| Other duties as requested. Incumbents may administer procedures and treatments and may operate and maintain special equipment and medical devices, operate equipment (such as the autoclave), make up sterile trays and packs. | 5 |
| Assist in various aspects of patient care like escorting the patient to the exam room, treatment room, with comfort to prepare for procedures, and overall comfort during the visit. As needed, assist with patient registration, observe, assist with the care and maintenance of patients and examining units; assist physician with physical examinations and treatments; weigh patients and take and record temperature, blood pressure, pulse, respiration; assist with the application and removal of protective and comfort devices; support and ambulate patients; assist with the ordering, care and conservation of hospital equipment and supplies; and may run errands and perform routine clerical duties. | 5 |
Knowledge, Skills & Abilities
| Knowledge/Skill/Ability | Requirement |
|---|---|
| Ability to read, write, and follow oral and written instructions. | Required |
| Attention to detail in recording detailed information. | Required |
| Speedy and accurate typing skills. | Required |
| Ability to organize and track multiple records and requests and follow through in a timely manner | Required |
| Ability to perform and multi-task under the pressure of frequent interruptions and distractions | Required |
| Ability to handle confidential material while protecting its strict confidentiality | Required |
| Demonstrated excellent verbal and written communication skills | Required |
| Ability to establish and maintain cooperative working relationships with co-workers, faculty, residents, nurses, students, university representatives, patients and the public | Required |
Special Requirements & Conditions
| Special Condition | Requirement |
|---|
Other Special Requirements & Conditions
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Level of Supervision Received
| Close Supervision |
Environment
Working Environment
| Medical Center/Clinic |
Other Requirements
Items Used
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Physical Requirements
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Mental Requirements
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Environmental Requirements
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Critical Position
| Is Critical Position: Yes |