Scribe- Jewett Orthopedic Institute, Melbourne

Orlando Health • Melbourne, FL

1d • Onsite

About The Position

Trained in structured clinical assessments, professional documentation, and team-based care in an ambulatory setting to prepare and assemble medical record documentation for providers in order to facilitate efficient and effective medical care between patients and clinical team members.

Requirements

• High school graduate or equivalent.
• Successful completion of an Orlando Health clinical documentation training program or Scribe training program within 60 days of hire.
• One (1) year of experience in a health care related position or health related education.
• Skilled in operating various medical record software and hardware, word-processing, and database software program

Responsibilities

• Gathers data through patient or caregiver interviews and direct or indirect observation of clinical team member.
• Documents clinical data, assessments, procedures, and patient education according to Orlando Health and department specific policies.
• Accurately and thoroughly document medical visits and procedures as they are being performed by the physician or APP.
• Prepares and assembles medical record documentation/charts for physician(s).
• Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
• Ensures medical record compliance by self-documentation attestation.
• Updates patient history, physical exam, and other pertinent health information in the patient.
• Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility specific procedures.

What This Job Offers

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