Fort Sanders Medical Scribe

Location: Premier Surgical Fort Sanders
Essential Job Duties and Responsibilities:
  • Accurately and thoroughly document medical visits and procedures as they are being performed by the physician and completed during each clinic visit.
  • Documenting medical visits including but not limited to:
    • Patient medical history and physical exam
    • Procedures and treatments performed by healthcare professionals, including MA, nurses, and physician assistants
    • 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
  • Prepare referral letters as directed by the physician, via dictation or summary of the medical record. Ensure that letters are mailed or faxed daily to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.
    • Spot mistakes or inconsistencies in medical documentation 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, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.
  • Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
  • Collect, organize, and catalog data for Physician Quality Reporting System and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.
  • Attend trainings on diverse subjects such as information technology, legal and regulatory compliance, billing, and coding. Quickly assimilate new knowledge into processes and procedures. Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
Education/Experience:

Minimum of a two-year degree, or two years or more experience in a medical office. Experience with digital transcription software, Intergy EHR, and medical coding training or certification are preferred but not required.