Medical Scribe - Ophthalmology Full-time Days

Northwestern Memorial Healthcare • Chicago, IL

1d

About The Position

The Medical Scribe supports Northwestern Medicine’s mission, vision, and values and follows its Code of Ethics, compliance program, policies, procedures, and applicable regulatory and accreditation standards. Under the direct supervision of a Provider, the Scribe is present during clinical services and documents patient encounters and related activity in the electronic health record in real time. The role also supports Provider productivity and workflow through non-clinical tasks such as navigating the EHR and locating information for Provider review. Scribes may not participate in clinical care or perform the prohibited activities described in the posting.

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 exposure to 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 to patients and/or family members.
• Accompany the Provider during patient interviews and examinations and accurately document encounter details and decisions in the EHR.
• Record relevant positive and negative findings, including history of present illness, medical and surgical history, social history, review of systems, medications, allergies, and family history.
• Document procedures and the Provider’s review of laboratory tests and diagnostic images or official radiologist interpretations.
• May record the timing of patient-care activities, including Provider-to-Provider communication, family communication, and patient re-examination.
• Assist with preparing paperwork for patient disposition from the clinic.
• Help Providers navigate the EHR and research or locate requested information, including previous notes, reports, test results, and laboratory results.
• Follow NMHC policies and applicable local, state, and federal guidelines for documentation, confidentiality, and privacy, including HIPAA.
• Ensure the medical record states that the document was prepared at the direction of and in conjunction with the Provider, includes the Scribe’s name and title, and includes the Provider’s attestation to the note’s accuracy.
• Generate and print the patient plan with the Scribe’s name at the bottom.
• Refer patient-care requests 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 password, or perform hospital duties.
• Perform other duties as assigned.

Benefits

• Northwestern Medicine states that it offers a wide range of benefits supporting physical, emotional, and financial well-being and protection against unexpected life events; detailed benefits and eligibility depend on employment classification.
• Tuition reimbursement.
• Loan forgiveness.
• 401(k) matching.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED