Scribe

Tufts Medical Center Boston, MA
* At the direction of a physician or licensed independent practitioner, the duties of the position are to document the physician dictated patient history, review of systems, medications and allergies, physical examination, family, social and past medical history as well as to document procedures, lab results, dictated radiographic impressions made by the supervising physician and other information pertaining to the patient's encounter in the outpatient clinic. The encounters are documented in real-time which allows the provider to spend more time with the patient while ensuring the documentation is accurate. Scribes are not patient care providers and thus provide assistance with all clerical activities related to the physician's practice. This assistance is under the direct oversight of the physician, where the physician will review and approve actions to be taken at key junctures during patient care. The final job description and roles to be assumed by the scribe will be tailored as needed. The intention is to minimize the physician's clerical functions while maximizing his/her clinical role, thus improving patient flow and satisfaction. Scribes can also assist the provider in navigating the EMR and locating information such as test and lab results. They can support workflow and documentation for medical record coding.

Responsibilities:

Assigned to work with one physician at a time.

Accompanies the physician in the exam room for the patient interview and examination

Documents the physician's dictated patient history, history of present illness, review of systems, past medical and surgical history, family and social history and allergies and medications.

Documents the physical examination findings as dictated by the physician and any procedures performed.

Lists diagnoses and symptoms as directed by the physician.

Documents lab and radiology results as instructed by the physician.

May document time spent on patient care related activities, MD to MD communication and patient re-examination, if applicable.

May be present and record the physician's consultations with family members or other physicians about a specific patient's case.

Documents any procedures performed by the provider including nurses.

May gather data about the patient prior to and following the visit including medical records from referring MDs, lab, radiology results and other data for review. May check for results of labs and tests ordered during a previous visit to ensure workup is complete and thus facilitate the provider's treatment decisions.

Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working groups achievement of goals, and to help foster a positive work environment

Performs other similar and related duties as required or directed.

Requirements:

Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process. This includes:

Knowledge of growth and development

Ability to interpret age specific data and response to care

Provide age specific communication)

Possesses the skills necessary to document patient care as dictated by a physician in a legible and clear manner, following any established guidelines for documentation.

Recognition of the physical exam process and have the ability to record exam detailed.

Possess a professional demeanor and demonstrate the ability to maintain confidentiality and privacy in accordance with HIPAA regulations.

Possesses organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.

Ability to multitask and maintain a sense of calm in busy and stressful situations.

Computer proficiency and understanding of the functions of an electronic medical record/

Familiar with medical terminology and technical spelling.

Two to four years of undergraduate education

Emphasis on biology or pre-medical studies preferred

1-2 years experience in a medical setting preferred

An equivalent combination of education and experience, which provides proficiency in the areas of responsibility listed above, may be substituted for the above education and experience requirements.