Scribe- FT
On-siteStuart, Virginia, United States
Job Summary
Accompany the physician on patient interviews and examinations to document accurate, thorough, and timely notes including history of present illness, review of systems, physical exam, and admission/discharge summaries. Record physician-dictated patient history, past medical and surgical history, family and social histories, medications, allergies, physical examination findings, procedures, and laboratory and radiographic study results. Assist the provider in applying appropriate billing codes and ensure documentation meets clinical requirements for risk management and billing. Maintain awareness of conversations regarding patient care to ensure applicable information is documented. Complete and present the medical record in collaboration with the supervising physician, who reviews and signs all documentation.
Required Qualifications
- High school graduate or equivalent
- The ability to work in a fast-paced environment
- Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation
- Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care
- Ability to multi-task and consistently communicate in a professional manner
- Strong communication skills, written and verbal
- Excellent listening and note-taking skills
- Detail oriented with proven ability to work effectively under conditions requiring accuracy
- Ability to remain calm in a fast paced, at times stressful environment
- Computer proficiency
- Upper-level typing/computer skills and proficiency
- Must be able to lift up to 15 pounds at times
Desired Qualifications
- Completion of a medical terminology course or one-year medical terminology experience in a clinical setting preferred
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