Medical Scribe

Altru Health System•Grand Forks, ND

22h•Onsite

About The Position

The medical scribe is responsible for supporting the organization's commitment to patient care and assisting physicians within Altru. The medical scribe demonstrates knowledge of medical documentation, clinical terminology, and facilitates communication between hospital staff to improve quality of life and efficiency within the department. The medical scribe performs thorough documentation of patient encounters, assignment of physicians to patients, and updates status of patients to ensure optimal patient experience and to alleviate physician workload.

Requirements

Proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.
Knowledge and understanding of medical documentation and terminology, as well as pertinent safety, health, and environmental policies, procedures, and guidelines.

Responsibilities

Performs thorough documentation of patient encounters, which includes history of present illness (HPI), patient chart or prescription medication review, review of systems (ROS), physical examinations (PE), electrocardiogram results (EKG) dictated by the physician, and discharge or hospital admission orders.
Demonstrates knowledge and understanding of medical documentation and terminology, as well as pertinent safety, health, and environmental policies, procedures, and guidelines.
Works safely, without causing harm or risk to self, others, or property.
Reports unsafe practices, procedures, accidents, injuries, or other safety violations to the leader.
Demonstrates improved department organization and workflow by providing updates from hospital staff, informing physicians of patients to be seen, suggests input of workup orders, and providing lab and imaging results.
Assists the physician in reviewing past medical, immunization, surgical, and prior encounter history.
Assists in assignment of physicians to patients and ensure accurate time documentation of patient interactions.
Performs other duties as assigned or needed to meet the needs of the department/organization.