Certified Medical Assistant / Medical Scribe

JOB SUMMARY

Under the direct oversight and presence of the Provider (Physician and / or Licensed Independent Provider), the Certified Assistant / Medical Scribe provides annotation, under their own login profile, into the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations / guidelines for documentation. The Certified Medical Assistant / Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. Work with the provider to provide patient care by performing tasks under the supervision of the physician. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.

PRIMARY JOB RESPONSIBILITIES

• Accurately and thoroughly document medical visits and procedures as they are being performed by the provider, including but not limited to :
• Patient chief complaint, reason for visit, medical history, review of systems and physical exam,
• Procedures and treatments performed by providers.
• Patient orders, including for example laboratory tests, imaging tests
• Patient education and explanations of risks and benefits.
• Provider-dictated diagnoses, codes, prescriptions and instructions for patient or family members for self-care and follow-up.
• Look up past medical records, tracking and entering results at the direction of the provider.
• Review the record and verify that the documentation requirements have been met for the designated codes assigned by the provider. Proofread and edit all the provider's medical documents for accuracy, spelling, punctuation, and grammar. Identify mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors, ensuring that all addenda are signed off by provider. Ensure that all clinical data, lab or other test results, the interpretation of the results by the provider are recorded accurately in the medical record, alerting provider when chart is incomplete.
• Comply with documentation compliance 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.
• Prepare referral letters as directed by the provider, via dictation or summary of the medical record. Ensure that letters are mailed or faxed on a daily basis to all providers involved in a patient's care, and with all copies of pertinent reports or tests attached. Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Collect, organize and catalog data for provider quality reporting system and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.

DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES

Work with the provider to provide patient care by performing tasks under the supervision of the physician such as :

JOB SPECIFICATIONS

EDUCATION

EXPERIENCE

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ESSENTIAL PHYSICAL ABILITIES / MOTOR SKILLS

These physical requirements are not exhaustive and additional job related physical requirements may be added on an as needed basis. Corrective devices may be used to meet physical requirements.

ESSENTIAL TECHNICAL ABILITIES

ESSENTIAL MENTAL ABILITIES

ESSENTIAL SENSORY REQUIREMENTS

INTERPERSONAL SKILLS