Medical Assistant Scribe

Primary Responsibilities and Essential Functions:

• Responsible for data entry into the Electronic Medical Record per provider instructions.
• Record a physician-directed patient history of present illness (HPI), past medical history (PMH), family and/or social history and physical examination (PE), including pertinent positives and negatives. Ensures transcription of handwritten or electronic physician notes, including but not limited to: verbal communication from the physician, patient/doctor interactions, physical exam findings, medical decision making, medication orders, laboratory results, radiological reports, clinical reevaluations, consultations and dispositions.
• Record procedures and the results of laboratory tests and radiographic images.
• Improve the efficiency of patient care by assisting the physician with routine matters.
• Assumes responsibility for other non-clinical assignments such as obtaining old medical records, and locating previous studies.
• Assists in routine clerical functions such as filing of medical information in patient's records, locating and compiling department charts, obtaining medical records from other providers and entering charges for billing purposes.
• Assists with back office duties when not directly assisting the physician with a patient.
• Prepares patient encounters to be seen by physicians.
• Assists provider with collection, documentation, processing, and verification of information related to patient care in an EMR system.
• Communicates patient concerns and needs to the healthcare provider timely.
• Completes assigned training and education as required and timely.
• Abides by all applicable Steward Policies and procedures including, but not limited to, safety matters, HIPAA-compliance and patient/computer confidentiality.
• Performs other duties as determined by the Practice Manager or Clinic Director.

Minimum Qualifications and Experience:

• High school diploma or equivalent.
• Previous experience as a Physician Document Assistant preferred.
• Basic knowledge of medical terminology.
• Preferred candidate would be a medical student, nursing student, paramedic student, medical assistant, EMT or CNA.
• Ability to maintain strict confidentiality/HIPPA confidentiality required.