Medical Scribe- Orthopedic Clinic- Baton Rouge

Ochsner Health • Baton Rouge, LA

1d • Onsite

About The Position

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today! This job assists Emergency Department physicians by documenting the entire medical record. Assumes responsibility for the creation and maintenance of the patient's medical record, which is done under the supervision of the attending physician. Documents the patient's history and physical, the physician's interaction with the patient, the procedures performed, the results of laboratory studies, and other pertinent information. Uses a COW (computer on wheels) which he/she takes with him/her throughout the shift. May be responsible for ordering laboratory/radiology studies, assisting with the patient's disposition, documenting consultations, and notifying the physician when important studies are completed. The Medical Scribe is not to make physical contact with or solicit information from patients, administer medication, relay verbal commands between physicians and nurses, or enter anything into a chart that has not been reviewed and approved by a physician. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.

Requirements

• Education Required - High School diploma or equivalent
• Work Experience Required - Experience working with medical terminology in a face-paced environment with minimal supervision
• Must have computer skills and dexterity required for data entry and retrieval of information.
• Effective verbal and written communication skills and the ability to present information clearly and professionally.
• Must be proficient with Windows-style applications, various software packages specific to role and keyboard.
• Strong interpersonal skills.
• Working knowledge of medical terminology.
• Excellent English language, grammar and punctuation skills in order to enter patient information and transcribe dictated medical reports into computer.
• Must be able to type 65 wpm accurately.
• Strong analytical, organizing and prioritizing skills.
• Ability to work and experience working in a fast-paced environment with minimal supervision and functioning calmly in a pressure situation.
• Ability to move throughout the department and facility.
• Ability to work flexible schedule with varying shifts, including nights, weekends, and holidays.

Nice To Haves

• Preferred - Currently enrolled in BNBS program or recent college graduate in the medical field
• Preferred- Bilingual capabilities
• Career goals in medicine including MD/DO, RN, NP, or PA

Responsibilities

• Documents the history and physical exam as it is being performed (real-time) by the ED physician.
• Transcribes all ancillary test results and the interpretation of the results by the physician, including any lab tests, imaging tests, ECGs and ABGs.
• Records physician-dictated diagnoses, prescriptions and instructions for patient discharge and/or follow-up.
• Understands the intricacies of the ever-changing documentation requirements, resulting in more complete medical charting and alerts physician when chart is under-documented.
• Documents procedures and treatments performed by the physician or any other healthcare professional, including nurses and physician assistants.
• Checks on the progress of lab, X-ray or other patient evaluation data and notifies the physician of ancillary tests when needed.
• Assists physician in rapid throughput of patients through the system from presentation to final disposition.
• Other related duties as required.
• Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

What This Job Offers

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