Physician Scribe/Secretary

Salem Regional Medical Center•Salem, OH

7d•Onsite

About The Position

The primary role of the medical scribe is to assist the physician with documentation of each patient’s medical chart. The scribe accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician. The scribe documents accurately the physician’s encounter with the patient and others present. The scribe, under the direction of the physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc. The scribe documents any procedures performed by the physician on the medical chart. The scribe transcribes any consultations or discussions with family and/or the patient’s private physician or the on-call physician. The scribe completes the patient’s chart by entering into the record results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to complete the patient’s workup so the physician is able to close the encounter. The scribe lists all proper diagnoses as well as any discharge/follow up instructions and prescriptions, as dictated by the physician. The scribe does NOT administer medications, does NOT relay verbal orders, and does NOT add anything to a medical record that is not under the direct order/supervision of their physician. The physician approves every task of the scribe and takes full responsibility, with their signature, for the information recorded in their patients’ charts. The scribe may be assigned to work as a Unit Secretary and assist with transporting patients when the physician is not working in the office.

Requirements

High school diploma/GED required.
Must have or obtain certification in Basic Cardiac Life Support (maintains currency of certification).
Familiarity with a healthcare setting.
Ability to demonstrate knowledge of medical terminology required.
Excellent English verbal and written communication skills.
Strong customer service skills.
Strong computer application skills required.
Ability to type quickly and accurately.

Nice To Haves

Ability to multi-task.
Ability to maintain a positive and professional demeanor under stressful circumstances.
Self-directing and proactive after understanding goals.
Strong analytical skills.
Time-management skills.
Flexibility to work as needed hours.

Responsibilities

Assist the physician with documentation of each patient’s medical chart.
Accompany the physician into the patient examination area to transcribe a history and physical examination.
Document accurately the physician’s encounter with the patient and others present.
Transcribe patient orders, including laboratory tests, radiology tests, and medications, under the direction of the physician.
Document any procedures performed by the physician on the medical chart.
Transcribe consultations or discussions with family and/or the patient’s private physician or the on-call physician.
Complete the patient’s chart by entering results of labs, x-rays, or other evaluations.
Continuously check on the progress of data to complete the patient’s workup.
List all proper diagnoses as well as any discharge/follow up instructions and prescriptions, as dictated by the physician.
Assist with transporting patients when the physician is not working in the office (may be assigned to work as a Unit Secretary).