Medical Scribe - Ophthalmology Full-time Days
About The Position
The Medical Scribe supports Northwestern Medicine’s mission, vision, and values and follows its Code of Ethics, Corporate Compliance Program, policies, procedures, and applicable regulatory and accreditation standards. Under the Provider’s direct supervision, the Scribe is present during clinical services and documents patient encounters and related activities accurately in the electronic health record in real time. The role also supports Provider productivity and clinic workflow through non-clinical administrative tasks. Scribes must not participate in clinical care or perform prohibited clinical and documentation activities.
Requirements
- High school diploma or equivalent.
- Proficiency in medical terminology and basic coding knowledge.
- Strong written and verbal communication skills and the ability to interact professionally with others.
- Strong attention to detail.
- Ability to actively listen and observe.
- Keyboard proficiency and ability to operate a personal computer and related software applications.
- Ability to multitask and work in a dynamic, highly stressful environment involving sensitive personal medical issues.
- Ability to problem-solve under pressure.
- Understanding of and commitment to protecting confidential patient information.
Nice To Haves
- Two years of experience working as a Medical Scribe.
- Medical Scribe certification through a vocational school, community college, or university.
- Bachelor’s degree.
Responsibilities
- Introduce themselves and their role as Scribe to patients and/or families.
- Accompany the Provider during patient interviews and examinations and document encounter details and decisions in the EHR.
- Record pertinent positive and negative findings from patient history and physical examinations, including history of present illness, medical and surgical history, social history, review of systems, medications, allergies, and family history.
- Record procedures and the Provider’s review of laboratory tests, diagnostic images, and official radiologist interpretations.
- When applicable, record the timing of patient care activities, including Provider-to-Provider and family communication and patient re-examinations.
- Assist with preparation of paperwork for patient disposition from the clinic.
- Assist Providers with EHR navigation and research information requested by the Provider.
- Locate information for Provider review, such as prior notes, reports, test results, and laboratory results.
- Follow policies and applicable local, state, and federal requirements for documentation, confidentiality, and patient privacy, including HIPAA.
- Ensure the medical record includes the required statement that the document was prepared at the direction of and in conjunction with the Provider, the Scribe’s name and title, and the Provider’s accuracy attestation.
- Generate and print the patient plan with the Scribe’s name at the bottom.
- Refer requests related to patient care to the responsible Physician or Nursing staff; do not participate in clinical care, add personal impressions to documentation, dictate reports, enter or write prescriptions, use a Provider’s login or passwords, or perform hospital duties.
- Perform other duties as assigned.
Benefits
- Tuition reimbursement
- Loan forgiveness
- 401(k) matching
- Benefits intended to support physical, emotional, and financial well-being and provide protection for unexpected life events
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
