The Medical Scribe reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The Medical Scribe observes and accurately enters details and decisions from practitioner-patient encounters directly into the (EHR) electronic health record on behalf of the Provider. The Medical Scribe is present during clinical services and accurately documents information, conversations and activity into the EHR in real time, under the direct supervision of the Provider.
Responsibilities:
- Identifies/introduces self and role of Scribe to patient and/or family.
- Accompanies provider during patient interviews and examinations.
- Records pertinent positive and negative findings in patient history and physical examination including history of present illness, past medical/surgical history, social history, review of systems, medications, allergies and family history.
- Records procedures, Provider review of lab tests, Provider review and impression of diagnostic images and/or review of official radiologist interpretations.
- May record time of patient care activities including Provider-to-Provider communication,family communication and re-examination of the patient.
- Assists with preparation of paperwork for disposition of patients from clinic setting.
- Helps increase Provider productivity and workflow by performing a variety of non-clinical tasks including:
- Assisting the Provider(s) in navigating the EHR.
- Researching information requested by the Provider.
- May locate information for review (i.e., previous notes, reports, test results, and laboratory results).
- Complies with all NMHC policies, including those relating to confidentiality of patient information, and all local, State and Federal guidelines for documentation, confidentiality and privacy (HIPAA).
- Ensures documentation in the EMR includes a statement that Document has been prepared at the direction and in conjunction with Provider along with the along with the Scribes name and title, and that the Provider has included an attestation regarding the accuracy of the note.
- Generates and prints patient plan with scribe name on bottom.
- Scribes are prohibited from participating in any clinical care (must refer all requests related to patient care to the responsible Physician or Nursing staff), interjecting own feelings, observations or impressions into the documentation, dictating reports, entering/writing prescriptions, using Providers log-in or passwords, or performing hospital duties.
- All other duties as assigned.
AA/EOE.