NI-Medical Scribe

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

3/23/2020

Entity:

Illinois

Job Code:

NI-2590CL

Job Title:

NI-Medical Scribe

Exemption Status:

Non-Exempt

JOB SUMMARY

Under the direction of the Operations Manager/Unit Supervisor the medical scribe is present with the physician during the patient visit for the sole purpose of transcribing physician documentation "real time" into Epic. The Scribe is responsible for accurate and timely transcription of physician notes in the clinic setting.  The goal of the Medical Scribe is to increase the efficiency and productivity of the physician.  This position will have no direct involvement in patient care.  Scribes are not permitted to make independent decisions or translations while entering information into the electronic health record.

Participates in continuous quality improvement and educational   support of departmental philosophy and objectives, as well as, Health System initiatives.

MAJOR RESPONSIBILITIES

•

Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician to produce a permanent record of patient care using Epic. Applies knowledge of medical terminology, anatomy, and English language rules to transcription and proofreading. Clarifies dictation that is unclear or incomplete, seeking guidance as necessary from the provider.

•

Uses reference materials appropriately as needed. Demonstrates understanding of medicolegal implications related to patient care medical records. Assists providers in maximizing use of systems to increase efficiency. Navigates the electronic medical record efficiently and accurately. Adheres to general organizational, department, and clinical policies. Assists educational process of new employees: responsibilities, procedures, and equipment. Interacts with patients in a friendly and courteous manner.

•

Interacts with and works around people in pleasant and professional manner. Makes judgments in demanding situations and react to frequent changes in duties and volume of work. and listens empathetically.

•

Ability to understand diverse accents, dialects, and varying dictation styles as demonstrated by high levels of accuracy in work. Is able to logically organize details. Comfortable accepting responsibility for medium to large scale projects involving multiple resources and spanning many months from start to finish.

•

Must be discreet, tactful, and unobtrusive in performance of duties so as not to distract from patient care

•

Ability to demonstrate proficiency in real time documentation in the electronic medical record. Is able to use reference materials as needed. Abstracts pertinent patient medical history in a timely manner.

•

Provides Physician with accurate and timely information regarding patient and documents information in appropriate records maintaining confidentiality at all times.

•

Schedules appointments, takes messages and maintains patient demographic financial information. Greets and directs department patients and visitors and provides assistance as necessary. Contributes to the efficient operation of the department by answering phones and providing a variety of clerical support.

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

X

Clinical

Provides age and culturally appropriate assessment/screening, interpretation of clinical and laboratory data and develops and implements age appropriate interventional and plans of care including education within the parameters of his/her position responsibilities and licensure.

JOB REQUIREMENTS

High School Diploma

or Equivalent.

Required

Education in medical secretarial, medical transcription, and/or graduate of accredited school or Graduate of an accredited Associate degree or diploma Medical Assistant program. In lieu of degree/diploma at least 3 years of experience in medical setting/field.

Required

1 year

of professional experience in a clinic setting.

Preferred

Experience with EMR.

Preferred

National Certification.

Preferred

•

Ability to learn computer and application skills as applicable to role.

•

Effective communication skills and excellent verbiage and spelling skills.

•

Must have exceptional listening skills and ability to concentrate in high levels of accuracy in transcription.

•

Medical terminology sufficient to transcribe in a medical setting.

•

Must be able to manage multiple concurrent activities and work independently, sufficient to complete work with minimal supervision.

•

Successful completion of annual clinical, age and job specific competencies and skill verification tools.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Standing

X

Walking

X

Climbing

X

Bending

X

Crouching

X

Pushing / Pulling

X

Carry

X

Fine Hand / Eye Coordination

X

Color Discrimination

X

Hearing Ability

X

Lifting / Lowering 1 -15 lbs.

X

15 - 30 lbs.

X

30 - 50 lbs.

X

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Concentration on Detail

X

Attention Span of 1 + Hours on a Task

X

Ability to Remember Multiple Tasks

X

Oral Communication

X

Written Communication

X

Exposure to Blood and Body Fluids

X

Exposure to Toxins, Cytotoxins, Poisons

X

Exposure to Extreme Heat, Cold, Temp Fluctuations

X

Exposure to Hazardous Chemicals

X

Exposure to Radiation

X

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.