Individuals appointed to position are capable of performing the function of a Scribe and are; therefore, responsible for timely clerical scribe duties within the Emergency Department unit. For any assigned shift a scribe is required to complete the duties below as assigned.
| Accompany physician in order to transcribe ED MD note, with physical exam, and document accurately the physician’s encounter with patient to include final diagnosis. |
| List all proper diagnoses and symptoms, chronic conditions, Family/ Social history within the documentation |
| Add follow up instructions and prescriptions as dictated by the physician. |
| Transcribe patient orders including lab tests, radiology tests, medications, etc. |
| Document any procedures performed by the physician during encounter. |
| Demonstrates strong communication
skills (i.e., appropriate use of tone of voice, diction, grammar, medical terminology). |
| Legible handwriting and ability to accurately record documentation during downtime procedures |
| Notify HIM director if physician is failing to complete documentation to include final diagnosis timely. |
| Complete dictation to include as much clinical information as possible during shift. |
| Complete dictation and assign to appropriate ED MD physician or attending for final review and signature. |
| Effectively communicates incomplete charts to the ED MD provider and helps to complete outstanding charts during each shift. |
| Professional demeanor and recognition of privacy considerations for patients and families |
| Responds appropriately and efficiently to various emergencies according to established procedures. |
| Review open deficient dictation(s) weekly to complete |
| Respond timely to any HIM deficiency request. |
| Reports unsafe conditions to proper staff and other departments. |
| Accepts responsibility for own actions and accepts constructive criticism. |
| Maintain an acceptable skill level with regard to computer use. |
| Demonstrates the ability to follow directions. |
| Must be able to establish and maintain effective working relationships with physicians, managers and peers |
| Completes duties in a timely manner. |
| Organize duties and functions. |
| Maintain a clean, safe, orderly area. |
| Perform duties with minimal supervision. |
| Perform other tasks as assigned. |
Must possess a high school diploma or equivalent. Medical Terminology and Clinical documentation validation experience required. Recent ER experience preferred (within 6 months) as a Scribe/Clerk/Tech. Demonstrated typing ability and computer experience required.