Summary:A scribe functions primarily to document the physician-dictated patient, history, physical examination, family, social, and past medical history. The scribe assists the physician with patient examination by observing and documenting procedures, education, lab results and physician-dictated radiographic impressions. The scribe works as part of a team with a common goal of offering excellent, timely and patient-centered care. This is accomplished using the relationship-based care model. The scribe in this role works with multiple electronic medical records and handles various types of patients in a busy outpatient clinical environment with a focus on effective teamwork and a welcoming attitude. Responsibilities:(70%)* The scribe will work with one physician while maintaining a friendly customer oriented attitude at all times. The scribe will accompany physicians into the patient examination room in order to transcribe a patient history, physical exam, and document family, social and medical history accurately from the physician�s encounter with the patient and others present. It is expected that the scribe will treat every person they encounter with kindness, compassion, and respect. The scribe will document the correct time of patient care related activities, including physician to physician interactions. The exam will be an important part of the documentation process.(20%)* When the physician concludes the patient encounter, the scribe will transmit the completed medical record to the assigned physician. The physician will review all documentation and sign the record before leaving the shift. The scribe will retrospectively review corrections and adjustments made be the physician periodically to continue education and performance improvement.(5%)* The Scribe is knowledgeable and compliant with all local, state, and federal regulations and guidelines. The Scribe maintains knowledge of MyMichigan Health Departments and/or physician office�s specific policies and procedures relating to the care provided, and maintains professional standards.(5%)* Scribes do not participate in direct patient care however they will assist with the no pass zone and other initiatives to improve the patient experience.OTHER DUTIES AND RESPONSIBILITIES:Safely Demonstrates awareness of specific safety concerns in department. Complies with MyMichigan Health safety guidelines. Maintain department equipment as necessary.Identifies and communicates concern regarding unsafe conditions or equipment promptly. Participate in medical center safety drills.Utilizes appropriate lift equipment on a routine basis.Attend education days. Seek opportunities for self-education and enrichment while sharing information with co-workers.It is expected that all team members will work together to provide the best possible care to MyMichigan Health�s patients, families, visitors, staff, community members, and any other person that is encountered while representing MyMichigan Health.Accurately and thoroughly document medical visits and procedures as they are being performed by the physician. Documentation shall include but is not limited to: patient medical history and physical exam, procedures and treatments performed by health care professionals, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.Record all telephone interactions.Review and check the Electronic Medical Record (EMR) for mistakes or inconsistencies and check to correct the information in order to reduce errors. All addenda must be signed off by a physician.Ensure that all clinical data, lab or other test results are accurately reflected in the EMR. Recognizes and displays pleasant, friendly and cooperative manner to public.Understand medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports.Translate medial abbreviations into their expanded forms.Completes documentation as required.Supports the mission, goals, policies, and standards of MyMichigan Health.Communicates identified problems to appropriate personnel and implements actions to assure patient needs are met. Assists unit in maintaining the area according to Joint Commission standards.Emergency Care/Safety Performs according to procedure in all medical center emergency situations.Provides and ensures safe and secure environment for the patient. Is familiar with all safety and emergency procedures.Observes fall safety precautions.Demonstrates competency in Infection Prevention and Control Practices and Policies.Possesses an understanding of infection prevention and control measures designed to prevent the spread of infectious diseases.Follows hand hygiene policies and utilizes personal protective equipment as required.MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft� Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.All other duties as assigned. Certifications and Licensures:Credential:BLS: Basic Life SupportEquivalent Experience: Within 3 months of hire or transferQualification Source: AHAEssential: trueRequired Education:Education: HIGHEquivalent Experience: A college degree or enrollment in a college degreed program is preferred.Education Specialization:Essential: trueOther Information:EXPERIENCE, TRAINING AND SKILLS:Experience with medical terminology is preferred.Experience as a medical transcriptionist is preferred.Strong writing, reading and computer skills.Knowledge of policies, and procedures as normally acquired through experience working in a medical center or similar setting.Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.Maintains confidentiality with all patient information and data obtained by following MyMichigan Health, State, and Federal guidelines.Organizational skills with a strong attention to details are needed to prioritize workload.Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear and understandable manner.PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.Overall vision and hearing is necessary with or without assisted device(s).Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.Physical Demand Level: Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.Equivalent Experience and Other Comments (Education):Education: HIGHEquivalent Experience: A college degree or enrollment in a college degreed program is preferred.Education Specialization:Essential: trueOther Comments:Credential:BLS: Basic Life SupportEquivalent Experience: Within 3 months of hire or transferQualification Source: AHAEssential: true
