Medical Scribe

North Georgia Eye Associates•Cumming, GA

13d

About The Position

A Medical Scribe accompanies a doctor during patient visits and documents interactions directly in the electronic medical record (EMR), allowing clinicians to focus on patient care. The role involves real-time documentation of patient history, diagnoses, treatment plans, and other medical information as dictated by the assigned doctor. Scribes work alongside doctors or surgeons and contribute indirectly to patient care. Basic ophthalmic and optometric knowledge can be acquired through on-the-job training, with basic competency expected within the first 90 days and advanced coding knowledge expected within the first six months.

Requirements

High school diploma or equivalent.
Typing speed greater than 60 words per minute.
Advanced active listening, time management, and attention-to-detail skills.
Strong communication and interpersonal skills.
Ability to work in a fast-paced clinical environment.
Maintain confidentiality and professionalism.

Nice To Haves

Prior experience with medical terminology and documentation.
Training in EMR software.
Basic knowledge of ophthalmic and optometric exams, procedures, pharmacology, and terminology; this knowledge may be obtained through on-the-job training.

Responsibilities

Document patient history, physical exams, diagnoses, treatment plans, lab and imaging results, and prescriptions in real time during consultations.
Navigate EMR/EHR systems, enter orders, update charts, and generate referral letters or prescriptions.
Review patient charts for completeness and accuracy and ensure documentation meets compliance standards, including HIPAA and audit requirements.
Assist with patient education about conditions as requested by the treating doctor or surgeon.
Maintain cleanliness and orderliness of exam rooms during the workday.
Follow practice procedures and protocols and comply with state and federal regulations.
Determine whether documentation supports E/M or Eye Code billing, match applicable ICD-10 codes, and code in-office procedures based on documentation.
Report inventory and supply needs to leadership in a timely manner.
Participate in daily team huddles and scheduled meetings.
Report potential or suspected errors to a supervisor or Compliance Officer.
Complete additional tasks or projects as needed to contribute to the team.
Maintain a positive, cooperative, self-motivated, courteous, and professional attitude.
Maintain confidentiality and professionalism at all times.