Medical Scribe

Overview

Job Summary:

Medical scribe assists the EM providers with documentation, transcription, and clerical functions to maintain an efficient workflow according to hospital policies and procedures.

Demonstrates through behavior Decatur Morgan Hospital’s mission, vision and values.

Responsibilities

Key Responsibilities / Essential Functions:

1.     Accompanying the emergency medicine provider to treatment space for patient evaluation.

2.     Record details of the chief complaint, history of present illness, review of symptoms, past medical history, social history, family medical history, disease risk factors, and any other patient information relevant to the presentation of the patient.

3.     Record details of the physical exam including pertinent positives and negatives, noted abnormalities, and patient general conditions as it is being performed and relayed by the provider.

4.     Use medical terminology and approved abbreviations in all medical record documentation.

5.     Capture all parts of patient care including things such as, but not limited to, critical care, end of life discussion, and smoking cessation counseling.

6.     Review previous visit records for important information including patients returning within 30 days of an inpatient discharge or returning within 72 hours of an ER discharge.

7.     Place calls to primary care providers, consultants, transfer centers, or other departments on be-half of the provider utilizing the hospital operator.

8.     Answer and field incoming calls to the provider lines in the emergency department.

9.     Follow up on the status of diagnostic tests, procedures, and imaging and alert the provider to review.

10.  Transcribe the results of tests, procedures, and/or imaging into the note after they are reviewed by the provider.

11.  Follow up on disposition of the patient for documentation including capturing discharge instructions, admissions, and/or prescription orders.

12.  Monitor patient tracker board and notify provider of new arrivals.

13.  Be sure that the provider reviews the documentation prior to the end of shift and make any edits necessary.

14.  Assist with incomplete charts by reviewing delinquencies with the provider.

15.  Participate in departmental and/or hospital process improvement initiatives including annual hospital goals.

16.  Complete annual HR and/or departmental requirements within specified time frame.

17.  Practice proper infection control practices including adhering to current isolation precaution guidelines.

18.  Use two patient identifiers when discussing or documenting patient information.

19.  Act in a manner that is cordial and respectful to co-workers, patients, and patients’ families.

Prohibited Functions

1.     Touching or examining the patient.

2.     Providing any clinical care or advice to patients or families.

3.     Administer medications to patients or retrieve medications from supply rooms or pyxis machines.

4.     Enter orders on behalf of the provider or use provider’s PIN to sign notes.  

5.     Receive critical reports from diagnostic tests such as labs or imaging.

Qualifications

Minimum Knowledge, Skills, Experience Required

Education:  Minimum high school diploma or GED required. Associates degree or some college preferred. Completion of scribe training program.

Experience: Minimum one year experience as an Emergency Medicine Scribe at Decatur Morgan Hospital preferred.

Additional Skills / Abilities: Must have excellent communication skills with the ability to function in a fast-paced environment and change tasks frequently and quickly. Requires computer and typing skills with demonstrated knowledge in rules of grammar including spelling and punctuation.