Medical Office Scribe BUMG Tucson Monday, Wednesday, Thursday Days
Apply NowLocation:
Tucson, AZ, US
Company:
Banner Health is one of the largest nonprofit health care systems in the country, leading in hospital services across various communities.
Summary:
The Medical Office Scribe records medical details and maintains patients' health information under the supervision of medical providers. Candidates must have a high school diploma or GED and preferred experience in an acute care setting.
Requirements:
Credentials: GED, High school diploma
Experience: Two years of experience in acute care or multi-specialty clinic using electronic medical record software or maintaining medical records.
Job Description:
POSITION SUMMARY
This position records medical details, gathers data, and coordinates tests, orders and results as necessary to ensure an accurate and complete medical record. Assembles and maintains patients' health information in medical records and charts by assisting medical providers and physicians. No medical decision making is performed.
CORE FUNCTIONS
1. Accompanies provider during patient examination.
2. Accurately and thoroughly documents pertinent patient information as instructed by the provider. Records details of chief complaint, history of present illness, review of systems, social history, past medical history, family medical history, allergies, medications, problems and diagnoses, history and physical, and any pertinent positive and negative findings.
3. May propose orders in the EHR based on clinical setting.
4. Documents details of procedures and treatments, laboratory test results, radiology test results and assists with documenting radiographic impressions performed by the provider.
5. Assists with verifying all tests (lab, x ray, EKG, etc.) have been completed and the results have been received, reviewed and recorded in the medical record.
6. Selects patient education leaflets from the EHR as instructed by the provider.
7. Assists in preparing paperwork for patient discharge.
8. Maintains confidentiality of all patient information.
9. Works under the direction of Physicians or independent licensed practitioner providing documentation assistance. Internal customers include patients, facility personnel, medical providers and physicians. External customers may include patient family.
MINIMUM QUALIFICATIONS
High school diploma/GED or equivalent working knowledge.
PREFERRED QUALIFICATIONS
Two years of experience in acute care or multi-specialty clinic using electronic medical record software or maintaining medical records.
Additional related education and/or experience preferred.
