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Scribe

Company: SSM Health
Location: Oklahoma City
Posted on: August 5, 2022

Job Description:

Accompanies provider into the patient examination room to document the provider's encounter with the patient. Collaborates with the provider to document the patient history, physical exam, results of diagnostic testing, and diagnosis and disposition.PRIMARY RESPONSIBILITIES

  • Assist providers with documentation of each patient's medical chart during encounters. Accompany the provider into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
  • Document all procedures performed by the physician, physician extenders, or nurses, on the medical chart.
  • Transcribe consultations or discussions with family and/or the patient's private physician or the on-call physician.
  • Complete the patient's charts by transcribing results of any labs, x-rays, or other evaluations. Continuously check the progress of data availability for orders, to ensure the patient's workup is complete so that the provider is able to make treatment decisions regarding that patient.
  • List all proper diagnoses as well as any discharge/follow-up instructions and prescriptions, under guidance of the physician.
  • May occasionally assist with some patient-related duties.
  • Performs other duties as assigned.EDUCATION
    • High school diploma or equivalentEXPERIENCE
      • No experience requiredPHYSICAL REQUIREMENTS
        • Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
        • Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
        • Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
        • Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
        • Frequent keyboard use/data entry.
        • Occasional bending, stooping, kneeling, squatting, twisting and gripping.
        • Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
        • Rare climbing.

Keywords: SSM Health, Oklahoma City , Scribe, Other , Oklahoma City, Oklahoma

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