Internal Scribe - Pain Management (Bala Cynwyd, PA)

Delaware Valley Management•Newtown, PA

13h•Onsite

About The Position

Completes patient medical chart in real time as the provider assesses and examines the patient by facilitating patient flow and ensuring an accurate and complete medical record for each patient using an Electronic Medical Records (EMR) system.

Requirements

Understands medical terminology.
Recognition of physical exam process and ability to record exam details.
Computer proficiency and ability to quickly learn new applications.
Hands on knowledge and use of medical EMR systems, ability to use eClinicalWorks EMR would be a significant asset.
Legible handwriting and ability to accurately record information.
Organizational skills with focus on tracking patient care and improving patient flow.
Professional demeanor and recognition of privacy considerations for patients and families.
Experience with Zoom, Microsoft Word/Excel/Office/Publisher/PowerPoint, Dropbox, Google Docs, and Outlook.
Must be patient and become proficient in deciphering physicians handwriting.

Nice To Haves

Any experience as a Medical Scribe preferred

Responsibilities

Accompany physician via zoom into the patient examination room to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present.
Review prior medical records to obtain past medical history information and prior labs, ECGs and radiographic studies for comparison.
Transcribe patient orders and all ancillary test results and their interpretations, including any lab tests, imaging tests, ECGs, radiology tests, medications, etc.
Document any procedures performed by the physician.
Accurately record provider’s consultations with other health care professionals, patients, and family members
List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
Understanding billing codes to help increase a provider’s charting efficiency.
Document procedures and treatments performed by providers.
Check on the progress of x-rays and other patient evaluation data.
Record provider-dictated diagnoses, prescriptions and instructions for patient discharge and/or follow-up.
Prep charts in EMR.
Communicate via email with attorney’s if necessary for patient care.