Medical Assistant - Scribe
- PRIMARY FUNCTION
Perform clerical and information technology functions for a physician in an electronic health records. Must be able to anticipate physician needs to facilitate the flow of the clinic. Perform clinical care essential to the assessment, promotion, maintenance and restoration of patient’s health and wellness.
- ESSENTIAL FUNCTIONS OF THE JOB
- This list may not include all of the duties that may be assigned.
- Manage patient care through an electronic environment.
- Ability to learn and appropriately apply basic medical terminology.
- Strong written and verbal communication skills.
- Demonstrate active listening skills, attention to details and able to spell accurately.
- Capture accurate and detailed documentation of patient encounter in a timely manner.
- Communicate and interacts with patients in a professional manner.
- Read previous visits to obtain follow-up plan as needed.
- Provide prescription information to pharmacies
- Assist provider by accurately documenting patient encounter including but not limited to chief complaints, barriers to care and community resources.
- Accurately document patient history detailing chronic illness, ER visits, hospitalization, significant past medical history, specialist seen and surgeries.
- Accurate documentation of patients’ allergies and OTC medications.
- Accurately documents review of system and a normal basic physical exam.
- Complete standing orders for labs and procedures when visit and age appropriate.
- Complete any necessary referral for provider approval.
- Measure and record patients' vital signs, such as height, weight, temperature, blood pressure, pulse and respiration.
- Check to make sure that patient history is complete (i.e. immunization records, allergy to medications, health record updates, etc...).
- Prepare treatment rooms for patient examinations, keeping the rooms neat and clean.
- Assist provider with any necessary procedures (i.e. ear piercing, suture removal).
- Perform sensory screening as needed.
- Fill out any necessary paper work for patient’s i.e. (school forms, medication forms).
- Call hospitals to obtain any necessary results i.e. (lab and x-ray results).
- Explain treatment procedures, medications, diets and physicians' instructions to patients
- Keeping a clean, safe and organized work environment for patients and staff.
- Attending any necessary meetings to be up to date on changes in protocol and procedures.
- Working as a team with nursing and front office staff for optimal patient care.
- Assisting the doctor in emergency situations.
- Having the knowledge and awareness of medications and supplies on crash cart.
- Administer immunizations and medicine injections if needed.
- Follow any OSHA and Safety requirements for rooms and documentation.
- During down time, assist with clinical duties assigned, including cross training in other functional areas.
- Complete all PA University mandatory courses by designated deadlines.
- PERFORMANCE REQUIREMENTS
- High School Diploma or equivalent. Medical Doctors must have a Bachelor of Science degree in General Medicine from a regionally accredited university or equivalent.
- MA Diploma or Certification
Knowledge, Skills & Abilities:
- Ability to perform necessary vital signs for pediatrics and obtain patient histories. Knowledge of basic medical terminology, and immunization requirements for children. Ability to assess emergency situations and act accordingly. Maintain effective working relationships with patients, employees and the public. Knowledge of medical safety practices and standard s. Ability to plan, prioritize, organize workflow. Ability to communicate clearly. Skill in maintaining department quality assurance. Skill in identifying problems and researching and recommending resolutions. Skill in preparing records, writing reports and responding to correspondence. Active CPR certification required.
- Prefer one year work experience in a medical office setting. Knowledge of computers.