Job Description

SUMMARY

The Medical Scribe is responsible for the operation of the electronic health records and electronic dictation system. This position requires for the Medical Scribe to be physically present at the Nursing Homes where the physician provides care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. The Medical Scribe must have the ability to quickly assimilate new knowledge into processes and procedures. The Medical Scribe will proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.

ESSENTIAL DUTIES AND RESPONSIBILITIES

include the following. Other duties may be assigned. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to: Patient medical history and physical exam, to include Procedures and treatments performed by healthcare professionals, including nurses and physician assistants Patient education and explanations of risks and benefits Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up Dictation/faxing/phone calls and clerical tasks Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned

MINIMUM QUALIFICATIONS

Bachelor's degree with pre-health career track preferred Degree or license in nursing or allied health fields Knowledge of medical terminology and human anatomy a plus Skilled in operating various medical record software and hardware, word-processing, and database software programs EEO / M/ F/ D/ V/ Drug-Free Workplace GA MedGroup

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