The requirements listed below are representative of the knowledge, skill, and/or ability required. Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar. Quickly assimilate new knowledge into processes and procedures. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. You will assist in developing and maintaining systems to track patient follow up and compliance.ĥ. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.Ĥ. Alert physician when chart is incomplete. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. All addenda must be signed off by a physician. Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.ģ. Medical Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Dictation/faxing/phone calls and clerical tasks. Prepare referral letters as directed by the physicianĢ.Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.Patient education and explanations of risks and benefits.Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
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