Scribe - Family Medicine Buena Vista

Responsibilities

Administrative/Clerical Support Accurate, timely charting of patient encounters to include, but not be limited to, patient history, physical exams, diagnostic findings, lab and test results, consultations with other providers, diagnoses, discharge instructions and prescriptions. Accompany the physician upon patient interview and examination. Document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Document physical examination findings and procedures as performed by the physician. Document the results of laboratory and radiographic studies as dictated by the physician. Document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient. When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter. All orders for patient care must be communicated by the physician and not the scribe. The physician and the scribe will make “chart rounds” to review patient status, delays, and any other care-related issues.

Qualifications

Education: High School diploma or equivalent.

Experience

Computer data entry experience. Previous clinical experience in a medical office preferred.