Practice Scribe

General Summary:

Accompanies physician during patient examination to transcribe
physician/patient encounter into patient medical record. Ensures medical record is accurate, complete, and meets medical coding requirements.

Essential Job Responsibilities:
1. Records relevant details of physician's interview with patient into medical record
(symptoms, patient and family medical history, list of medications, etc.).
2. Documents physician's physical examination of patient (measurements, vital signs,
observations and findings).
3. Records results of testing, including physician impressions of test results.
4. Enters physician diagnoses and follow-up instructions.
5. Maintains confidentiality, privacy, and appropriate demeanor during interactions with
patients and health care team members.
6. Ensures accurate, complete and consistent selection of diagnosis and procedural codes
to assure the production of quality healthcare data and accurate payments.
7. Reviews patient records for completeness of documentation and requests physician
clarification for any incomplete or ambiguous data.
8. Performs related duties as required by supervisor or manager.

Requirements:

• High school diploma or general equivalency diploma (GED)
• Higher education also accepted, not required.
• Minimum one year of relevant experience working in a medical facility or related field.
• Orthopedic experience preferred.

Additional Details:

The following schedule and travel is Required:

• Monday - Lynbrook (8:30am-5pm), Tuesday - Lynbrook (11am-7pm), Wednesday - Massapequa (12:00pm-8pm), Thursday - Lynbrook (8:30am-5pm), Friday - Rockville Centre (Medphones)
• Flexibility to travel to Bohemia (Mondays) and Merrick (Wednesdays)