Major Responsibilities:In accordance with policy, prepares and assembles medical record documentation/chart for physician prior to patient visit.
Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results.
Ensures that all elements of documentation are complete and accurate.Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications.
Documents the physician/clinician’s communication with the patient using appropriate medical terms and phrasing.Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders.
Documents the correct follow-up instructions and level of service designation based on the physician/clinician’s direction.
Assists in data entry from devices or other sources.Completes medical records for each encounter ensuring accurate and timely documentation.
Under physician/clinician direction, updates patient history and other pertinent health information in the patient record.
Prepares and sends all documentation for review and approval.With proven competency, may perform clinical functions such as prepare and room patient for exam, obtain vital signs and document/update pertinent health information, assist the physician/clinician with non-sterile procedures, schedule appointments and referrals to other facilities or services, and perform other data entry into the EHR.Licensure, Registration, and/or Certification Required:None Required.Education Required:High School Graduate.College-level courses completed: Medical Terminology; Anatomy & PhysiologyExperience Required:Requires 1 year of experience in medical transcription, emergency medical services, or as a health care professional with demonstrated proficiency in medical terminology and technical spelling.Knowledge, Skills & Abilities Required:Successful completion of Aurora authorized medical scribe training course within 30 days of hire.Knowledge of medical terminology, including basic human anatomy and coding.
Demonstrates familiarity with medication names and medical procedures.Knowledge of essential elements of documenting a provider-patient encounter, HIPAA compliance, and Centers for Medicare and Medicaid Services requirements.Excellent communication and interpersonal skills.
Ability to maintain sensitivity and confidentiality for the patient while assisting physician.
Ability to develop rapport and maintain positive, professional relationships.Requires adherence to all policies and procedures, including but not limited to standards for safety, patient service, attendance, punctuality, and personal appearance.Proficient computer skills including: advanced keyboarding, above average typing speed, navigation within a windows operating system, and use of electronic mail with exposure to electronic medical records systems.Ability to effectively multi-task, with excellent prioritization and organization skills.Must have a high attention to detail and accuracy when documenting health information.Ability to work effectively in a fast paced and stressful environment.Must have ability to travel to various work locations.Physical Requirements and Working Conditions:Exposed to a normal medical office environment.Position requires travel; therefore may be exposed to severe weather or road conditions.Must have functional speech, vision, hearing, and touch with ability to use fine-hand manipulation skills.May need to occasionally lift/carry up to 20 lbs.May be exposed to the following hazards: mechanical, electrical, chemical, blood and body fluids; therefore must wear protective clothing and equipment as needed.Operates all equipment necessary to perform the job.
This job description indicates the general nature and level of work expected of the incumbent.
It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent.
Incumbent may be required to perform other related duties.