Scribe

The Scribe will document information in the electronic medical record at the direction of the physician or advanced practice clinician. The Scribe will document the provider's dictation and/or activities. Any individual serving as a Scribe will have no patient care responsibilities or offer clinical oversight. An individual serving as an in-person Scribe may also serve as a chaperone during sensitive exams after completion of required education.

• Education: High School Diploma or GED, required. 4 Year / Bachelors Degree, preferred. 
• Experience: Six months customer service environment experience in the medical field, preferred. 
• Additional Skills (required): Working knowledge of medical terminology and technical spelling. Computer aptitude and ability to quickly learn new applications. Communication and organizational skills with focus on tracking patient care and improving patient flow. Ability to record information accurately and promptly. Aptitude to learn or have knowledge of exam, diagnostic and treatment procedures and protocols. Professional demeanor and recognition of privacy considerations for patients and families. Completion of the computer-based learning entitled AMB0742 NHMG Chaperone in the Exam Room if the Scribe will also be serving as a chaperone during sensitive exams.
• Additional Skills (preferred): Specific medical terminology training, knowledge of basic anatomy, coding and HIPAA familiarity, medical, procedural and diagnosis coding experience.

• Document physical examination findings, procedures, and provider-dictated diagnoses in real-time.
• Enter lab results, imaging studies, and consultant reports into EPIC.
• Prepare and review medical records for completeness, accuracy, and provider signature.
• Document time-stamped activities, including patient re-examinations, provider communications, and updates. 
• Accompany providers into patient rooms to capture encounter details during the visit.
• Maintain strict patient confidentiality and adhere to HIPAA regulations.