Scribe – Per diem – Auburn Community Hospital

Job Title: Scribe – Per Diem – Auburn Community Hospital

Job Description:

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.

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