Description :

1. Performed by the physician, including but not limited to: patient medical history and physical exam; procedures and treatments performed by healthcare professionals.
2. 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.
3. Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician, were recorded accurately in the medical record.
4. Complied with specific standards that applied to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
5. Responsible for medicine, healthcare terminology, and record-taking expedited a physicians' day and streamlined their health care delivery.
6. Performed in-depth health care summaries on each patient encountered, often introduced the patient's case to a physician prior to clinic visits.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Keeping patient's notes up to date after every visit including updating any new medical history, recent surgeries, medication allergies, new medications, new experienced symptoms etc.
2. Putting in new imaging information such as X-rays, CT scans, pathology, PET/CT, Bone Mineral Density Scans, Mammograms and Ultrasounds into patient's records.
3. Making sure if patient had recently been admitted to a hospital all of their laboratory work, imaging and consultation notes are obtained from their admission.
4. Accompany medical provider during patient's interview and physical examination and update patient's chart with any new findings while patient's visit.
5. Sending patient's most recent note to their Primary Physician or any other physician which is taking care of the patient in order to keep them informed of any new treatment patient may be started on or new imaging results we may have obtained.
6. Obtaining any needed records or test results that were conducted in a different physician's office prior to patient's visit.

Experience

2-5 Years

Level

Executive

Education

B.S

Description :

1. Proficient in medical terminology and billing & coding, update and chart patient's history, reconcile medications, physical exam, assessments, diagnoses, and plan of care as dictated by the provider.
2. Identify mistakes or inconsistencies in the documentation and under supervision of provider, correct the information in order to reduce errors.
3. Alert provider when a chart is incomplete, and comply with legal and ethical standards for preparing medical documents and for keeping patient information confidential.
4. Understand Meaningful Use requirements in order to generate appropriate educational documents for the patient on smoking cessation, medications, and procedures.
5. Make and receive phone calls; generate referrals, recommendations, and letters for the patient on behalf of the provider.
6. Set up medication schedules as dictated and under the supervision of the provider.
7. Upload Prescription Monitor Reports into EHR on behalf of the provider from the State's Prescription Monitoring Program Website.

Experience

2-5 Years

Level

Junior

Education

Master

Description :

1. Responsible for scribing medical charts into EPIC EMR during patient encounters and maintaining 8-15 charts simultaneously within a fast-paced, ER environment.
2. Scribe medical providers' charts in real-time according to individual preferences to increase Emergency Room efficiency by reducing provider downtime spent charting individually.
3. Maintain 10-20 patient charts and enter updated information/test results as they become available.
4. Extensive knowledge working with the EPIC EMR system to document medical charts.
5. Part of an implementation team to bring the first scribe group to the Alta Bates Summit Medical Center Emergency Room.
6. Increased provider efficiency by reducing downtime caused by self-charting.
7. Reduced chart-downloading by ensuring all charts satisfy required billing points.
8. Customer Service Initiative Adaptability Flexibility Active Listening Fast Typing Speed Organization Attention to Detail.

Experience

2-5 Years

Level

Executive

Education

B.S

Description :

1. Documents 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.
2. Documents physical examination findings and procedures as performed by the physician.
3. Documents the results of laboratory and radiographic studies as dictated by the physician.
4. Documents the correct time of patient care-related activities, including physician to physician communication, family communication and re-examination of the patient.
5. Maintains and demonstrates an understanding of the team approach to patient care and documentation.
6. Completes and presents the medical record in collaboration with the supervising physician.
7. Pursues continuing education through clinical experiences to enhance knowledge in the promotion of quality documentation.

Experience

2-5 Years

Level

Junior

Education

B.A

Description :

1. Create new patient admission and progress notes by researching computerized and paper charting for current and past medical, social and family history.
2. Responsible for medications and physician orders, with attention to recent vital signs, labs and imaging studies.
3. Reviews nursing notes and communicates with nursing staff to prioritize the order in which patients should be seen.
4. Accompanies physician on rounds in skilled nursing and ICF setting, assists with documenting each patient visit.
5. Responsible for Generates billing statements; organizes physicians' paperwork.
6. Managed all physician paperwork, enabling him to make more efficient use of his time.
7. Built healthy working relationships with facility personnel and communicated with the healthcare team to better serve the client.
8. Informed the doctor of urgent patient needs per nursing progress notes.

Experience

7-10 Years

Level

Executive

Education

Masters

Description :

1. Facilitated patient flow and ensure an accurate and complete medical record for each patient.
2. Documented patient's visit and description of illness to the emergency room while staff physicians examine the patient.
3. Responsible for the creation and maintenance of the patient's medical records under the supervision of attending physician.
4. Physicians to do what they do best and make patient diagnoses with ease without having to take notes.
5. Utilize electronic health records and medical records, tablets, and iPads for patient data entry.
6. Relive physicians of administrative work associated with practicing medicine.
7. Ensure that documentation is accurate to bill patients for services rendered.

Experience

2-5 Years

Level

Junior

Education

M.S

Description :

1. Accompany the provider into the patient examination room to accurately and efficiently document the encounter.
2. Exhibit excellence in medical terminology and billing and coding knowledge in all documentation.
3. List all proper admission or discharge diagnoses as well as follow-up care instructions as dictated by the provider.
4. Document the time and reasoning for, but not electronically submit, patient orders including lab tests, radiology tests, and medications.
5. Successfully navigate the location-specific Electronic Medical Record (EMR) system to input documentation.
6. Make and receive phone calls on behalf of the provider. and Document any procedures performed by the provider.
7. Inform the provider when diagnostic studies are completed, prepare for the review, and document in EMR.

Experience

0-2 Years

Level

Fresher

Education

Diploma

Description :

1. Take Patient's vitals including Weight, Height, Pulse Oximetry, Heart Rate, Fall Risk Questionnaire, Depression Screening.
2. Exhibit excellence in medical terminology and billing & coding knowledge in all documentation.
3. List all proper admission or discharge diagnoses as well as follow-up care instructions as dictated by the provider.
4. Document the time and reasoning for, but not electronically submit, patient orders including lab tests, radiology tests, and medications.
5. Document any procedures performed by the provider(s).and Organized and Scanned Medical Records into the Patient's Chart.
6. Successfully navigate the location-specific Electronic Medical Record (or EMR) system to input documentation and ICD 10 trained.
7. Inform the provider when diagnostic studies are completed, prepare for the review, and document in EMR.

Experience

2-5 Years

Level

Junior

Education

Master

Description :

1. Assist providers with charting by inputting a history of present illness, review of symptoms, physical examination, diagnosis, and plan into each chart.
2. Create after visit summaries to give to patients, upload and title images, and perform other miscellaneous tasks as needed.
3. Document any procedures performed by the provider(s).and Organized and Scanned Medical Records into the Patient's Chart.
4. Successfully navigate the location-specific Electronic Medical Record (or EMR) system to input documentation and ICD 10 trained.
5. Maintain constraints in a fast-paced environment to continue working on previous patient charts while starting new ones as needed.
6. Responsible for keeping track of phone calls made to other facilities and Physicians. 
7. Responsible for putting radiology results and lab results into the chart once they have resulted.

Experience

2-5 Years

Level

Executive

Education

B.S

Description :

1. Organize all of the patient's laboratory tests, medications, imaging studies, ect..
2. Document all procedures completed by the physician and record all diagnostic test results.
3. Document any consultation the physician may make to the patient's personal physician, consulting physician or family member.
4. Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge & follow up instructions.
5. Exhibit excellence in medical terminology and billing and coding knowledge in all documentation.
6. List all proper admission or discharge diagnoses as well as follow-up care instructions as dictated by the provider.
7. Greeting guests upon arrival, seating them and making sure they are happy with everything during their dining experience.

Experience

2-5 Years

Level

Entry Level

Education

B.S

Description :

1. Assisted Emergency Department Physicians create medical charts using various electronic health records systems.
2. Researched relevant past medical history related to patient care, and documented accordingly.
3. Documented dictations regarding ongoing care of patients in a highly critical setting, including updating lab results, imaging studies and procedural care.
4. Establish and maintain effective working relationships with physicians, staff, and management.
5. Responsible for Effective communication and the accurate document was a must. 
6. Responsible for ensuring timely, accurate and complete medical records for each patient.
7. List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physicians.

Experience

2-5 Years

Level

Junior

Education

M.S

Description :

1. Worked in the emergency department at Carroll Hospital Center.
2. Consisted of overseeing the documentation of each patient's visit to the emergency department, and acting as the physician's personal assistant.
3. Alerted on call physicians when needed Kept patients comfortable during their stay.
4. Transported patients to different locations Skills Used As a scribe I was required to constantly communicate with both doctors and patients to ensure a fluent turnover rate of patients.
5. Attended examinations with physicians and created electronic medical records in the emergency departments of Tallahassee and Quincy campuses.
6. Aided the emergency department, specifically the Physician I was assigned to each day, in performing vital tasks for the optimal performance emergency patient care.
   
7. Worked as part of a team supporting the Emergency Room doctors.

Experience

7-10 Years

Level

Management

Education

Bachelor's In Biology

Description :

1. Documented the correct time of patient care related activities, including physician-to-physician communication, family communication, and re-examination of the patient.
2. Listened and take notes while accompanying the provider to the patient room or receiving verbal dictation.
3. Documented accurate, thorough and timely physician notes in the electronic medical record that reflect the full complexity of care provided.
4. Ensured physician notes meet clinical documentation requirements for risk management, billing, etc.
5. Informed the provider of any incomplete documentation and seek out the information to complete the note
6. Monitored the status of the patient’s course, troubleshoot delays, and keep the customer informed of pending items i.e., waiting for x-ray to be done, all lab results back, etc.
7. Assisted the provider in navigating the EMR.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Obtained past medical history and family history as appropriate. 
2. Obtained or reviewed medications patient is currently taking and medication patient is allergic to. 
3. Recorded all of the above information in patients chart and sign.
4. Assisted physicians and nurse practitioner with examinations as necessary. 
5. Lifted patients on and off exam tables and into and out of wheelchairs.
6. Generally, kept examination rooms clean, neat, organized. 
7. Kept supplies, equipment and instruments in place and ready for use

Experience

2-5 Years

Level

Executive

Education

BA In Biology

Description :

1. Transcribed dictated reports and translate medical jargon and abbreviations into their expanded forms.
2. Identified mistakes in reports, and check with doctors to obtain the correct information.
3. Performed data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
4. Produced medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
5. Returned dictated reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
6. Reviewed and edited transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.
7. Taken dictation using either shorthand or a stenotype machine, or using headsets and transcribing machines; then convert dictated materials or rough notes to written form.

Experience

2-5 Years

Level

Executive

Education

MS