Medical Associates Plus
Augusta , GA 30906
Posted 1 week ago
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The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated made by the supervising physician and any other information pertaining to the patients encounter in the medical clinic.
- Assigned to work with one physician per shift.
- Accompany the physician upon patient interview and examination.
- Document 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.
- Document physical examination findings and procedures as performed by the physician.
- Document the correct time spent on patient care related activities including physician to physician communication, family communication, and re-examination of the patient.
- When the physician concludes the patients encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patients encounter.
- The physician and the Scribe will make chart rounds to review patient status, delays, and any other care-related issues.Additional
- Maintain and demonstrate an understanding of the team approach to patient care and documentation.
- Complete and present the medical record in collaboration with the supervising physician.
- Be responsive to improvement opportunities in a positive manner.
- Communicate in a professional and respectful manner to the supervising physician and staff.
- 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 an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
- Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
- Health Care Plan (Medical, Dental & Vision)
- Retirement Plan (403 b,)
- Life Insurance (Basic, Voluntary & AD&D)
- Paid Time Off (Vacation, Sick & Public Holidays)
- Family Leave (Maternity, Paternity)
- Short Term & Long Term Disability
- Training & Development
- Wellness Resources