The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter in the Medical Group departments.
This position is a flexible, hourly role ideal for those interested in gaining firsthand experience in a medical setting while contributing to patient care.
ResponsibilitiesMedical Scribes are assigned to work with one physician per shift.
Medical Scribes accompany the physician upon patient interview and examination.
Medical Scribes 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.
Medical Scribes document physical examination findings and procedures as performed by the physician.
Medical Scribes document the results of laboratory and radiographic studies as dictated by the physician.
Medical Scribes 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.
Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc.
PATIENT CONFIDENTIALITY MUST BE MAINTAINED AT ALL TIMES.
QualificationsCandidate should have an understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. One year medical terminology experience is desirable.
Must have some working knowledge of computers and typing experience as well as excellent and legible penmanship. Ability to multi-task and consistently communicate in a professional manner. Punctuality and preparedness for all shifts and work-related activities. Must comply with department dress code.
Location : Location US-VA-Norfolk