POSITION
DESCRIPTION
|
POSITION
SUMMARY: As an unlicensed
member of the team, this person is responsible for documenting the
physician’s or licensed independent practitioner’s dictation and/or
activities into the medical record. |
MINIMUM
QUALIFICATIONS: |
|
EDUCATION,
CERTIFICATION, AND/OR LICENSURE: |
|
1. |
High
School Diploma or equivalent required. |
PREFERRED
QUALIFICATIONS: |
|
EDUCATION, CERTIFICATION, AND/OR LICENSURE: |
|
1. |
Two years of college level coursework in applicable
course of study (i.e. biology, chemistry, physics) preferred. |
CORE DUTIES AND RESPONSIBILITIES: The
statements described here are intended to describe the general nature of work
being performed by people assigned to this position. They are not intended to be constructed as
an all-inclusive list of all responsibilities and duties. Other duties may be assigned. |
|
1. |
For history of present illness, past medical
history, review of systems, medications, social history, family history, allergies
or other elements of the patient chart: The physician or licensed independent
practitioner will elicit the
information as usual and Scribes will record the information in the chart for
approval. |
2. |
The Scribe may accompany the physician or licensed
independent practitioner in the patient
examination area in order to transcribe a history and physical examination as
given by the patient and physician or licensed independent practitioner. |
3. |
The Scribe documents in the medical chart any
procedures performed by the physician or licensed independent practitioner, or nurses. |
4. |
The Scribe transcribes any consultations or
discussions with family and/or the patient’s private physician or the on-call
physician. |
5. |
Scribes may gather laboratory results, radiology
results, medical records and other data for review by the physician or licensed
independent practitioner. Data should
not be entered into the EMR, chart, or otherwise incorporated into the
medical record until it has been reviewed and approved by the physician’s or licensed
independent practitioner. |
6. |
Scribes must continuously check on the progress of
this data in order to get the patient’s workup complete so that the physician or licensed
independent practitioner is able to
make treatment decisions. |
7. |
The Scribe may not provide verbal orders or relay
verbal orders between the physician or licensed independent practitioner and other patient care providers. The physician or licensed independent practitioner must communicate orders directly to other care
providers. |
8. |
Scribes can make and answer calls for the physician or licensed
independent practitioner, however
Scribes may not take medical data over the phone. |
9. |
Scribes may not give medical advice, communicate
medical information or care plans of any kind directly with the patient or
patient’s family or friends. |
10. |
Scribes can communicate waits and delays as directed
by the RN or physician
or licensed independent practitioner. |
11. |
Scribes may print the physician’s or licensed
independent practitioner process at the physician or licensed independent practitioner’s direction. |
PHYSICAL REQUIREMENTS: The
physical demands described here are representative of those that must be met
by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities
to perform the essential functions. |
WORKING ENVIRONMENT: The work environment
characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities to perform
the essential functions. |
SKILLS AND ABILITIES: |
|
1. |
Working knowledge of
medical terminology and accepted abbreviations. |
2. |
Computer proficiency and
ability to quickly learn new applications. |
3. |
Communication skills and
the ability to coordinate and cooperate with multiple members of the health
care team. |
4. |
Organizational skills
with focus on tracking patient care and improving patient flow. |
5. |
Professional demeanor
and recognition of privacy considerations for patients and families. |
6. |
Typing speed of 50 wpm
preferred. |
7. |
Position is subject to
core competencies and quality assurance monitoring. |
Date
Reviewed/Revised: November 2017 |