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Scribe

Company: St Luke's Hospital of Chesterfield MO
Location: Chesterfield
Posted on: August 7, 2022

Job Description:

Description

To facilitate patient flow and enable a physician to focus on patient care during office visits, the Scribe is responsible for entering real-time patient encounter documentation in the electronic medical record (EMR) at the direction of a physician. The Scribe accompanies the physician during the medical history-taking and physical exam, and records details of both in the EMR. The scribe reviews pertinent past medical records, enters vital signs and prescriptions, and is responsible for tracking lab values and imaging study results, and bringing critical results to the physician's attention. The Scribe enters required clinical data to support quality documentation requirements. The Scribe performs duties and responsibilities in a manner consistent with our mission and values.

Principle Accountabilities: % of Time Spent

1. Record details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications, and allergies. At the direction of the physician-record details of physical exam, including pertinent positives and negatives, noted abnormalities, and patient general condition. Record orders and details of the treatment plan, as directed by the physician. Enter clinical patient data to support quality documentation requirements. 40%

2. Review patient's pertinent past medical records, enter vital signs and prescriptions, track lab values and imaging study results, and bring critical results to the physician's attention. 25%

3. Submit documentation to the provider for review of accuracy and completeness, for the physician's signature, and performs other duties as assigned. 25%

4. Perform other medical assistant and administrative assistant duties as needed and assigned. 5%

5. Perform other duties as assigned. 5%

Total: 100%

Education

High school diploma or equivalent required. Graduate of MA program and/or medical assisting experience. RMA, CMA, NCMA, CCMA, ABR-OE, or comparable credential preferred.

Experience

At least one year of experience in medical office or hospital department, or graduate of MA program preferred.

Knowledge of medical terminology and familiarity with coding and medical abbreviations preferred.

Basic computer skills required, and electronic medical record documentation experience strongly preferred.

Working Conditions

The assessment, care and treatment provided by the medical assistant will be consistent with the specific age-related needs of the patient. The medical assistant is competent to care for patient age groups consistent with the specialties of the physician(s) in the practice.

Employee is required to sit, stand, and walk frequently. Employee must lift/carry a light (1-20 lbs.) load frequently, a medium (21-50 lbs.) and/or heavy (50 lbs. +) load occasionally. Employee may be required to lift over 100 lbs. with assistance. Employee is occasionally required to bend, squat, crawl, kneel, climb, lift waist to overhead. Employee is occasionally required to reach forward and reach overhead. Employee may be required to do simple grasping and pushing/pulling.

(Occasionally: 1-33%, Frequently: 34-66%, Continuously: 67-100%)

The most significant of duties are included but this does not exclude occasional work assignments not mentioned or developmental duties.

Job Relationships: Brief descriptions of the types of interactions that occur for this job.

Takes direction from: Office Manager, Physicians, Nurse Practitioner

Provides direction to: N/A

Supervised by: Office Manager

Mission/Values

Mission

Faithful to our Episcopal-Presbyterian heritage and its ministry of healing, St. Luke's is dedicated to improving the health of the communities we serve.

Using talents and resources responsibly, we provide high quality, safe care with compassion, professional excellence and respect for each other and those we serve.

Vision

As an independent healthcare network, we create healthy communities in the region through our commitment to high quality, safe and personalized services.

Core Values

Human Dignity

We accept and treat all persons as being created in the image of God.

Compassion

We respond with caring to the needs of others as if they were members of our family.

Justice

We honor each person's rights and responsibilities in light of the common good.

Excellence

We set and strive to attain high standards of performance and continuous improvement.

Stewardship

We use our talents and resources wisely, with honesty and integrity.

Keywords: St Luke's Hospital of Chesterfield MO, Chesterfield , Scribe, Other , Chesterfield, Missouri

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