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Why You'll Love This Job

The duties the Health Information Assistants (Scribes) are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter. Scribes are not patient care providers.

Major duties and responsibilities:

  • Scribes accompany the physician upon patient interview and examination.
  • Scribes document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Scribes document physical examination findings and procedures as performed by the physician. Scribes document the results of laboratory and radiographic studies as dictated by the physician. Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.  
  • When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.  
  • The physician and the Scribe will make “chart rounds” to review patient status, delays, and any other care-related issues.
  • All orders for patient care must be communicated by the physician and not the Scribe.
  • 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.

 

 High school graduate 

Excellent and legible penmanship 

Ability to multi-task and consistently communicate in a professional manner 

Completion of a medical terminology course or one year medical terminology experience in a clinical setting

 

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