Overview

This position serves as a representative of the physician. The position is responsible for documenting the physician-dictated patient history, physical examination, family, social, and past medical history. Documentation will also include procedure notes, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient's encounter. The essential functions of a scribe are: a) A scribe will accompany the physician upon patient interview and examination. b) A scribe will 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. Scribes document physical examination findings and procedures as performed by the physician. c) A scribe will document the results of laboratory and radiographic studies as dictated by the physician. d) A scribe will document the correct time of patient care related activities, including physician to physician communication, family communication, and reexamination of a patient. e) A scribe will not sign patient encounters. When the physician concludes the patient's encounter, the physician will review all documentation completed by the scribe. The physician will then make, if necessary, any amendments and sign the chart. Ultimately, the physician is responsible for documentation of the patient's encounter. f) The scribe and physician will make chart rounds to review patient status, delays, and any other care related issues. g) All patient care orders must be communicated by the physician and not scribe. h) A scribe will not participate in any patient care and should refer all requests related to patient care to the assigned physician or nursing staff. This may include: transporting specimens, answering phones, assisting patients, and calling physicians.

Qualifications

Minimum Education and Experience Requirements::High school diploma or equivalent preferred; completion of a college level medical terminology course and completion of a computer skills training class preferred. Necessary Skills: 1. Knowledge of basic Anatomy & Physiology 2. Demonstrates the ability to learn and apply all hospital computer technologies and procedures that affect patient care delivery 3. An understanding of patient confidentiality/HIPAA, adhering to all ethical and legal requirementsMotor Vehicle Operator Designation (Required): (Refer to CP 1.51):Will not operate vehicles for an assigned business purposeLicensure/Certification/Registration::None
Minimum Education and Experience Requirements::High school diploma or equivalent preferred; completion of a college level medical terminology course and completion of a computer skills training class preferred. Necessary Skills: 1. Knowledge of basic Anatomy & Physiology 2. Demonstrates the ability to learn and apply all hospital computer technologies and procedures that affect patient care delivery 3. An understanding of patient confidentiality/HIPAA, adhering to all ethical and legal requirementsMotor Vehicle Operator Designation (Required): (Refer to CP 1.51):Will not operate vehicles for an assigned business purposeLicensure/Certification/Registration::None