at NorthShore University Health System in Chicago, Illinois, United States
Job Description
JOB SUMMARY
A Medical Scribe performs all clerical and information technology functions for a physician. The duties of a Medical Scribe are to document the patient history, physical examination, social history, family history, past medical history, impressions made by the physician, and any additional information pertinent to the patient's visit. The position does not have direct involvement with patient care and works under the supervision and direction of a physician. The purpose of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working with.
RESPONSIBILITIES
Essential Functions
Demonstrates a commitment to the mission of Swedish Hospital/Medical Group and demonstrates a service orientation and adheres to all policies, responsibilities and standards of the organization.
Access to Protected Health Information "Computer System access is assigned based on manager's access level request and on the minimum necessary described in this job description.
Accompany the physician into the exam room and accurately transcribe the patient's history and physical exam.
Transcribe all pertinent diagnoses, symptoms, and any follow-up instructions.
Document performed procedures and treatment.
Prepare and print or publish to the patient portal patient education material.
Create referrals and letters as directed by the physician.
Perform other duties, including administrative duties, as needed or assigned.
Policy and Procedures:
Observes department policies and procedure, environment and infection control standards.
Interprets hospital policies, regulations, standard to other staff, patients and visitors to ensure compliance.
Attends required all required in-services on system improvement, Safety, Infection control, etc.
Observes OSHA regulations including principles of standard precautions.
Cleans the exam/treatment rooms after each patient and/or procedure including equipment used in accordance with infection control guidelines.
PATIENT CARE/AGE SPECIFIC RESPONSIBILITIES AND QUALIFICATIONS
This position will need to recognize growth and development characteristic, needs and behaviors of early and middle adult patients who have sustained work related injury/illness and to understand the effect of disability and lost time at work on injured workers. The ability to identify a variety of issues which sometimes interfere with the recovery process. The incumbent must possess the ability to deal effectively all age groups from infants to senior citizens.
QUALIFICATIONS/BASIC JOB REQUIREMENTS:
Education:
High School Diploma or equivalent
Experience/Skills
Experience: 1-2 years in a physician's office or an ambulatory care setting experience.
Bi-lingual Preferred
Comprehension of Medical Terminology
Ability to type 70 words per minute accurately in grammatically-correct English.
Strong organization and interpersonal skills with the ability to multi-task efficiently and effectively.
Ability to effectively use basic office software (Excel, Outlook, Word, etc.)
Ability to calmly and effectively able to handle busy or stressful situations.
Ability to communicate effectively in the English language in person, by phone and in writing.
Requires adherence to all policies and procedures, including but not limited to standards for safety, attendance, punctuality and personal appearance.
Knowledge of CPT & ICD-10 coding procedures.
LICENSE/CERTIFICATION
Certification or registration as a Medical Assistant with a nationally recognized accrediting body preferred.
Current CPR certification with the American Heart Association or American Red Cross required.
INTERNAL AND EXTERNAL CONFLICTS
Frequent contact with patients, visitors, employers, physician, nurses and insurance companies.
ENVIRONMENT
Primary body position: Sitting = 50%, Standing/Walking = 50%
Lifting requirements up to 50 lbs occasionally or frequently
Potential exposure to airborne diseases: 100% of the time
Potential risk of blood borne exposure: 100% of the time
Some travel outside the hospital is involved using own transportation: 0%
Requires full range of body motion including handling and lifting of patients, manual and finger dexterity and eye-hand coordination 100% of the time.
ACCESS TO PROTECTED HEALTH INFORMATION
Computer system access is assigned based on manager access level request and on the minimum necessary as described in this job described in this job description. Approval for level of access is given by the system administrator or manager of the department that has ownership of system/module.
The above statements are intended to describe the general nature and level of work performed by employees assigned to this classification and the specific functions of the individual occupying... For full info follow application link.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.
