Job detail

Scribe- Jewett Orthopedic Institute, Melbourne

Orlando Health

#Electronic Medical Record #Orthopedics #Patient Education #Clinical Assessments #Sports Medicine #Ambulatory Care #Medical Scribe #Healthcare Documentation

Quick overview

The Scribe is responsible for documenting clinical data, assessments, and procedures in real-time during patient visits. They prepare medical record documentation and ensure all charts are accurate and compliant for physician review.

Requirements summary

Candidates must be high school graduates with one year of healthcare-related experience or education. Successful completion of a clinical documentation or Scribe training program is required within 60 days of hire.

high schoolWord ProcessingData EntryClinical DocumentationMedical ChartingElectronic Medical RecordsDatabase SoftwarePatient InterviewingMedical Transcription

Job description

Position Summary

One of the region’s largest orthopedic and sports medicine providers, Orlando Health Jewett Orthopedic Institute’s world-class team of orthopedic surgeons and sports medicine physicians specialize in conditions and injuries of the spine, hand, upper extremities, foot, ankle and lower extremities, as well as joint replacement, concussions, interventional pain management, bone health and orthopedic trauma. The institute also holds official medical roles with multiple athletic teams, sporting events and venues. In its first year of eligibility, the institute has been recognized for its positive workplace culture with Modern Healthcare’s Best Places to Work award. 🔗 Click here to learn more about Orlando Health Jewett Orthopedic Institute 💼 Position Overview Trained in structured clinical assessments, professional documentation, and team-based care in an ambulatory setting to prepare and assemble medical record documentation for providers in order to facilitate efficient and effective medical care between patients and clinical team members

Responsibilities

Gathers data through patient or caregiver interviews and direct or indirect observation of clinical team member.
Documents clinical data, assessments, procedures, and patient education according to Orlando Health and department specific policies.
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician or APP.
Prepares and assembles medical record documentation/charts for physician(s).
Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
Ensures medical record compliance by self-documentation attestation.
Updates patient history, physical exam, and other pertinent health information in the patient Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility specific procedures.

Qualifications

Education/Training High school graduate or equivalent. Licensure/ Certification Successful completion of an Orlando Health clinical documentation training program or Scribe training program within 60 days of hire. Experience One (1) year of experience in a health care related position or health related education. Skilled in operating various medical record software and hardware, word-processing, and database software program