GENERAL SUMMARY/ OVERVIEW STATEMENT



The Urogynecology Medical Scribe duties include performing all clerical and information technology functions for and under the direction of a physician by documenting in the electronic medical record (EMR). Medical Scribes must be professional and discreet in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are required when working as a Medical Scribe. This position is a per diem and only up to 5 hours per week.



PRINCIPAL DUTIES AND RESPONSIBILITIES



1. Document in the EMR for the physician during or after patient clinical visits or encounters. This includes documenting the patient medical and social history, physical exam, assessment and plan, diagnoses, medications, results, procedures, and treatments, and follow-up instructions. The medical scribe will be expected to learn and understand basic documentation requirements.


2. Works to facilitate patient flow and ensure accurate and complete medical record for each patient.


• Accompanies physician into patient examination room, or virtually to accurately document the physician's encounter with the patient and others present following established policies and guidelines.


• Lists all proper diagnoses and symptoms as well as follow up instructions, orders and prescriptions as dictated by physician.


• Documents physician dictated, printed or handwritten patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications, and allergies during the visit exam.


• Documents all procedures performed by physician.


• Documents physical and pelvic exam findings and procedures performed by the physician.


• Documents the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.


• Creates and queues medication, laboratory, and other orders for physician to authenticate and initiate. All orders for patient care must be communicated by the physician and not the scribe.


• Creates and maintains guide of Urogynecology physician documentation preferences.


• Medical Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to transporting specimens, answering phones, assisting patients, calling physicians, etc.


3. Assists the provider with all clerical activities related to the EMR. To help support workflow and documentation for medical record coding. Assists provider in navigating the EMR and locating information such as tests, lab results, and hospital dictation.


• Responds to messages as directed by physician.


• Searches and collects pertinent past medical histories, test results, external medical records, or other needed patient information requested by physician.


• Prepares referral letters and other patient care correspondence as directed by physician.


• Assists physician with obtaining or locating information in EMR or other systems as needed.


4. Ensures good teamwork and effective interpersonal relationships. Communicates effectively and handles confidential matters per policy and procedures.


• Recognizes sensitive situations and seeks appropriate guidance.


• Monitors personal work ethic, behavior, and attitude.


• Maintains strong and effective relationships with peers, staff, physicians, agencies, and other organizations consistent with MGB, BWH and OBGYN policy and standards.


• Works to improve patient satisfaction.


• Identifies opportunities for process improvement related to quality initiatives.


• Actively participates in recommending plans of action to address any identified issues.


• Complies with national and local PHI laws including HIPAA and HITECH policy standards.


• May perform other non-clinical tasks as directed by supervisor or designee.



Qualifications

QUALIFICATIONS:



1. High school diploma or equivalent is required, Bachelor's Degree desirable.


2. Must be able to read, write legibly, speak clearly, and understand the English language.


3. Based on physician and practice operational needs, may be asked to change work schedule and/or location. At times there may be little notice. Changes are typically short-term and long-term changes will be reviewed and discussed by manager.



SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:



1. Previous EMR experience preferred.


2. Completion of a medical terminology course or one year experience working with medical terminology in a clinical setting is highly desirable.


3. Ability to multi-task and consistently communicate in a professional manner and perform duties under pressure.


4. Adequate knowledge of computer usage and ability to tolerate viewing on computer monitors for extended periods of time.


5. Able to establish and maintain collaborative working relationships with physicians, administrators, clinical managers, and other staff.


6. Strong attention to detail



EEO Statement

BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.