Job Description
Under the direction of the Physician, Clinical Manager, Registered Nurse or Program Director, will perform tasks supporting physician transcription. While performing tasks, under the supervision of the physician, strong customer services are essential. Position will provide clerical support during the delivery of patient care, recording physician's dictation into Electronic Medical Record (EMR) in real time. Participates in maintaining a safe patient environment at all times. Possess strong verbal communication and comprehensive skills.
ESSENTIAL FUNCTIONS INCLUDE BUT ARE NOT LIMITED TO:
Accompany physician into the patient examination room in order to transcribe a history, physical exam, assessment and plan.
Document accurately the physician's encounter with the patient and others present.
List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
Document any procedures and/or hyperbaric treatments performed by the physician.
Review past medical histories, previous visit encounters, past results and studies.
Understand basic ICD-10 documentation requirements.
Comply with hospital and medical facility polices, including those relating to HIPAA and Joint Commission
Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
Experience Required:
At least 1 year of medical terminology
At least 1 year of medical scribe/medical transcription experience.
Must complete and pass required medical screening, background checking and drug test
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