Vacancy expired!
Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms. We are looking for an individual trained in medical documentation to assists the physician throughout his shift. Your primary goal is to increase the efficiency and productivity of the physician while he is working.
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
Patient medical history and physical exam,
Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
Patient education and explanations of risks and benefits.
Physician-dictated diagnoses, prescriptions, and instructions for patient or family members for self-care and follow-up
Prepare referral letters as directed by the physician
Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Ensures that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab, or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when the chart is incomplete.
Requirements/Skills:
Language Skills -The ability to write routine reports and correspondence.
Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
Mathematical Skills – Ability to add, subtract, multiply, and divide into all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.
MUST BE A CMA (CERTIFIED MEDICAL ASSISTANT) TO CALL IN SCRIPTS, PROCEDURES, ETC.)
