Required Experience: No experience required

Required Education: Graduate of a state accredited school of Nursing, Licensed Practical Nursing or Medical Assistant program. Current Iowa license and BLS certification.

Position Summary: Assist in handling time-consuming clerical responsibilities for physicians during patient encounters to promote efficiency and patient-centered care. Scribes accompany the physician and directly observe patient encounters. They accurately document the events and decision-making in a manner that results in appropriate medical charting. Scribes also complete activities necessary to assist with processing of physician orders for tests and medications.

Essential Function:

• Maintain established departmental procedures, objectives, quality assurance programs, environmental and infection control standards, and hospital policies including compliance policies.
• Maintain patient documentation and that patient records are treated as confidential information. Adheres to the policies and procedures regarding HIPAA Guidelines.
• Communicate with various departments to assure proper service to patient.
• Complete accurate, timely and thorough document of patients medical visits and procedures as they are being performed by the physician to include (but not limited to): medical history, physical exam, procedures and treatments performed by the healthcare professionals, patient education and explanation of risks and benefits, physician-dictated diagnoses, prescriptions, instructions for patient or family members for self-care and follow-up, and prepare referral letters as directed by the physician.
• Abide by all documentation policies and procedures set in place according to the regulatory and compliance requirements.
• Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation and grammar.
• May assist the physician by preparing and mailing/faxing referral letters daily to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. Research contact information for referring physicians, coordinate referrals, prepare reports, and make phone calls and other clerical duties as assigned.
• Conducts interactions with patients in a professional, non-intrusive manner with physicians, hospital staff and co-workers.
• Assist in spotting mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.
• Continuous, high-level of communication with the physician in all matters relating to patient care to include notifying a physician when a chart is incomplete.
• Abide by the legal and ethical requirements for preparing medical documents and keeping patient information confidential.
• Assist in developing and maintaining systems to track patient follow-up and compliance.
• Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
• Satisfactorily qualifies for the position through an Iowa Criminal History / Dependent Adult Abuse check within the limits of applicable laws.

Additional Job Requirements:

• Attend meetings as required.
• Perform other related duties as assigned or requested.

Soft Skill Requirement:

• Promote good intra and inter hospital communications and relationships.

Physical Requirements & Working Conditions:

Working Conditions: May be exposed to infections and contagious diseases. Regularly exposed to the risk of bloodborne diseases. Contact with patients under wide variety of circumstances. Exposed to unpleasant elements (accidents, injuries, and illness). Subject to varying and unpredictable situations. Handles emergency or crisis situations. Performs emergency care. Occasionally subjected to irregular hours. Occasional pressure due to multiple call and inquiries. Requires judgment/actions which could result in death of patient.

Required PPE:

Eye protection

Face protection

Gown

Mask

Sterile medical gloves

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be constructed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.