Scribe

JOB SUMMARY AND SCOPE

Performs clerical and information services functions to support efficiency and productivity of the physician. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important. Must be adaptable and versatile. Accomplishes secretarial functions to support the provision of care within the physician department. Interacts with patients, families, and staff members to maximize successful patient outcomes.

Performs medical assisting functions to support the provision of care within the physician department. Interacts with patients, families, and staff members to maximize successful patient outcomes.

ESSENTIAL JOB FUNCTIONS

• Monitors and assists with patient flow
• Accurately and thoroughly documents 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,
• Patient education and explanations of risks and benefits,
• Physician instructions for patient or family members for self-care and follow-up
• Comply with standards that apply to Electronic Medical Records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
• Proofread and edit the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
• Assists with coordination of scheduling.
• Checks charts routinely for omissions and compliance
• Prepares the patient charts daily, as necessary.
• Greets and prepares patient for office visit or outpatient procedure.
• Obtains vital signs and weighs each patient.
• Assists in procedures requested by the medical provider.
• Checks charts routinely for omissions and compliance.
• Maintains sterilization process of all instruments.
• Makes referral and prescription calls per medical providers orders per protocol.
• Screens calls including emergency calls.
• Assure that all necessary release and consent forms are signed.
• Performs lab testing according to set protocols and maintains daily, monthly, and yearly compliance.
• Performs look up per protocol on the Maine Prescription Monitoring Program.
• Performs Medication Authorization as needed.
• Communicates with patients via various communication avenues, including secure messaging.
• Maintains compliance with all hospital policies as well as compliance with all State, Federal and CMS policies of licensing and certification.
• Responsible to always maintain medical record privacy and security according to hospital policies and procedures.
• Demonstrate a clear understanding of, and commitment to, the hospital’s mission, vision, and values as well as the service excellence standards while completing all tasks and responsibilities.
• Provides coverage for other DECH physician offices when necessary.
• Seeks out needed information by staying informed and involved by attending meetings, reading memos, policies, meeting minutes, newsletters, e-mail and other appropriate information in a timely manner.
• Uses patient handling equipment appropriate to the needs of the individual patient in keeping with the Safe Patient and Handling and Movement Policy.
• Reliable attendance and punctuality, including observing appropriate break times and extending a scheduled shift when necessary to meet patient demands
• Performs duties in a safe manner, in compliance with all safety policies and procedures
• Complies with the Code of Conduct and all appropriate policies and procedures
• Other duties, as assigned, that are relevant to the position and department

*DECH is an equal opportunity employer.

Requirements

MINIMUM REQUIREMENTS

• Ability to work with the public
• Able to handle multiple tasks simultaneously
• BLS
• Immunization and injection administration, vision & hearing, phlebotomy
• Medical Assisting Degree or appropriate training.
• MA certification preferred, required within 6 months of hire
• Ability to understand and listen to complex medical terminology; be able to summarize in a clear, complete, and concise fashion.
• Proficient in typing, telephone communication, Microsoft Office (Word, Excel, and Outlook)

PHYSICAL EFFORT AND ENVIRONMENT

Clinical: Frequently lifts up to 35 pounds independently. Frequently pushes/pulls 100 pounds using mechanical and other assistive devices. Walks, stands, kneels, bends most of the time. Exhibits fine motor skills and manual dexterity necessary to perform the essential job functions of the position. Visual acuity correctable to 20/20. Color vision is necessary. Normal hearing acuity.

EXPOSURE RISK

Exposure Category I: Employee at risk for exposure to blood borne pathogens.

QUALITY IMPROVEMENT

• Maintains current knowledge of the hospital-wide Quality Improvement Program.
• Collaborates with management to improve the effectiveness of the department through the Quality Improvement plans and processes.
• Participates in the departmental and hospital-wide Quality Improvement activities as directed by the manager.

COMPLIANCE

• Adheres to the federal, state, and local statutes and regulations.
• Adheres to the Compliance Program policies and procedures of Down East Community.
• Adheres to all Privacy and Security policies and procedures of Down East Community.
• Communicates any concern related to compliance issues to manager of department or Compliance Officer.
• Communicates any concern related to confidentiality issues to the Privacy Officer.