Scribe

Job Details: Job Location: Countryside

• Clearwater, FL, Position Type: Part Time, Education Level: High School, Salary Range: Undisclosed, Travel Percentage: Up to 50% , Job Shift: Day, Job Category: Clinical Back Office, Position Summary: The Medical Scribe ensures accurate and timely documentation of the medical chart under the supervision of the medical provider. The Scribe assists the provider by accompanying them during the patient exam recording detailed information into the electronic medical record (EMR). The Scribe performs other related medical record or clerical duties to increase provider effectiveness, efficiency, and productivity for improved patient flow and satisfaction. When not Scribing, the Scribe may be used as clinical support to physicians and patients who are seen, served, and treated by Ear Nose & Throat Associates (ENTA) as a Medical Assistant. Reports to: Clinical Director Flexibility: While this job description is meant to provide an overview and specific responsibilities of the Medical Scribe, ENTA Management reserves the right to make changes, adjustments and revisions, as needed, to this document and will coordinate such modifications with ENTA’s Practice Administrator and Physicians. While the normal work week is 40 hours, you may be subject to overtime (not to exceed 50 hours per week). These hours may vary based on the clinic’s needs. You may at some point be required to travel to other offices if coverage needs arise. Summary of General Duties: Responds to tasks created in the EMR and is responsible for communicating any patient concern to the appropriate Physician, bringing any relevant data that will guide physician in the decision-making process. Directs hospital referrals to the appropriate physician on call. Respond to any other requests from Physicians or management team as appropriate. Be a team player: look to see how you might assist fellow MA’s or front staff during daily operations to ensure a smooth flow of clinic hours. Always represent ENTA and its staff and Physicians in a professional, courteous, and respectful manner on or off property. Summary of Scribe Specific Duties: Update and add supporting information to the HPI started by medical assistant. Listen to physician during exams and update exam accordingly. Populate assessment with Diagnosis codes. Input orders and associate them with appropriate diagnosis codes as well as make sure required documentation is in the note before routing to physician. Input procedure codes and associate with appropriate diagnosis codes as well as make sure required documentation is in the note before routing to physician. Include patient’s referring physician and PCP as recipients of the note. Create procedure notes. All notes including diagnosis codes, billing codes, orders and sending orders to central orders be input and sent to the physician within 15 minutes of the last patient being checked out. At times the physician will dictate specific details into the instructions portion of the note and the scribe will be expected to type these into the instructions. Input medications and send medications to the pharmacy within 1 hour of the appointment. The Scribe will not be expected to input or send controlled substances. Those medications will be sent by the physician. Tasks sent to the physician will also be sent to the scribe. While in clinic the scribe will be expected to check tasks and verbally relay questions to the physician and respond to the sender. On the physician operating room (OR) days the scribe will be expected to check the tasks in the AM and PM and relay urgent tasks via text message or calling into the OR to prevent any delay in patient care. E-Prescribe medications when directed by physicians. Facilitate refills when appropriate. Answer patient questions or refer to Physician. Notify Clinical Director of any problems with patient care. Direct computer issues to the IT Director. Direct Greenway problems to the EMR Director. Department only- OSHA or HIPAA call supervisor and wait for her to arrive) and show through rooms with Biohazard containers, Biohazard waste box, and State Biomedical waste plan (64E-16) in OSHA book. Ensuring medical record compliance by self-documentation attestation to include Scribe name, title, and doctor working for as well as specific date and time entry Preparing and sending all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures Monitoring the duration of basic lab results and screening procedures Compliance with hospital and Pro. Scribe policies, including those relating to HIPAA and Joint Commission Regular and reliable attendance at assigned facility required. Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned. Summary of Medical Assistant Specific Duties Greets patients and directs them to room for Physicians visit. Updates or populates patient chart with relevant medical data Responds to tasks created in the EMR and is responsible for communicating any patient concern to the appropriate Physician, bringing any relevant data that will guide physician in the decision-making process. Assist Physician with any procedures. Directs hospital referrals to the appropriate physician on call. Respond to any other requests from Physicians or management team as appropriate. Be a team player: look to see how you might assist fellow MA’s or front staff during daily operations to ensure a smooth flow of clinic hours. Always represent ENTA and its staff and Physicians in a professional, courteous, and respectful manner on or off property. Working Environment: Physical demands: Coordination, manual, and physical dexterity sufficient to properly and adequately use various items of medical equipment and office equipment as required of the position or directed by the Clinical Manager. Average percent of time during regular shift devote to: Walking, Squatting, Sitting, Bending, Reaching: 75% Standing: 25% Average lifting requirements: Lifting Requirements: 20-40 lbs. Frequency of Lifting: 0-25% of the time Additional physical demands: Ability to grasp with both hands; pinch with thumb or forefinger; turn with hand/arm; reach for (above shoulder height). Ability to type 60 wpm. Ability to operate multi-line telephone system, computer keyboard and ten-key adding machine. Visual, Hearing, and Mental demands: Vision adequate to perform essential functions such as read telephone displays/computer terminals for long periods of time, correctable to 20/20. Hearing is adequate to perform essential functions such as answering the telephone. Mental capacity adequate to perform essential functions such as quickly and accurately entering patient demographics and scanning documents while checking in multiple patients. Tact to deal with unfriendly individuals regarding various situations, and adequately handle stress. Working Conditions: Normal business office environment. Requires individual to be in uniform daily. Required to exhibit a positive attitude and a professional appearance and show great detail and accuracy. Required to exhibit quality performance of the essential job functions to help the office run effectively and efficiently.

Qualifications

High School education or GED equivalent. Minimum two years of medical office experience. Must have own/ or reliable source of transportation due to requirements of potential travel to other offices when/as needed Working knowledge of general office duties. Good verbal and written communication skills. Good telephone skills.

Demonstrated ability to use a computer with Microsoft Word, Outlook and EMR software. Excellent customer service skills. The ability to attend work on a regular basis. The ability to adhere to safety rules and other reasonable regulations pertaining to the job. The ability to refrain from negativity or excessive irritability.

The ability to work in cooperation with other workers. Strong organizational skills with the ability to multi-task. Ability to expertly document patient care and transcribe patient appointments Advanced computer skills Confidentiality and privacy of the patients Strong organization, multitasking and time management skills Ability to handle high-pressure situations effectively Good bedside manner and interpersonal skills Ability to work in a fast-paced environment Ability to learn and appropriately apply basic medical terminologies and techniques taught Strong written and verbal communication skills Strong attention to detail and instruction Ability to observe and to draft a narrative account of events accurately and grammatically correct Ability to spell, proofread, and edit written documents Keyboard proficiency (approximately 60 words/minute) Ability to operate a personal computer and related software applications Ability to communicate and interact professionally with physicians and other healthcare professionals Understanding of and commitment to the appropriate protection of confidential patient information