Description

Position Title: Medical Scribe

Department: Health Information Management

Reports To: HIM Director/Attending Physicians

FLSA Status: Non-Exempt

Summary:

The Medical Scribe will work closely with attending physicians in a fast-paced Long-Term Acute Care Hospital (LTACH) setting, providing documentation support for patient census. The scribe will assist in real-time charting, ensuring accurate and efficient electronic health record (EHR) documentation to enhance physician productivity and patient care.

Duties and Responsibilities (includes, but not limited to the following):

• Accompany physicians during rounds, documenting history & physicals (H&Ps), progress notes, consult notes, discharge summaries, and orders in the EHR.
• Record physician-patient interactions, exam findings, assessments, and treatment plans accurately.
• Update patient charts with lab results, imaging reports, and consultant recommendations.
• Ensure timely completion of medical documentation to meet compliance and billing requirements.
• Assist in reconciling medication lists, problem lists, and past medical history. Format notes according to hospital policy (SBAR). 
• Prepare pre-rounding reports by reviewing patient charts for updates.
• Flag critical lab/imaging results for physician review.
• Coordinate with nursing and ancillary staff to streamline communication.
• Adhere to HIPAA and hospital confidentiality policies.
• Maintain accurate records for audits and quality metrics.
• Collaborate with physicians, nursing staff, and case managers.

Supervisory

•  This position has no direct supervisory responsibilities.

Skills and Abilities

• Speed, consistency and accuracy in tasks
• Ability to demonstrate flexibility in work environment, performing a variety of frequently changing tasks.
• Sustain concentration and prolonged commitment to job task.
• Ability to express and communicate through good verbal and written skills
• Ability to understand, carry out and remembering instructions.

Experience and Qualifications

• Prior medical scribe experience (1+ year preferred), especially in hospital, LTACH, or critical care settings.
• Must know terminal digit filing system and file records on shelves as needed. 
• Electronic Health Records system experience preferred.
• High Speed Scanner 
• Basic computer skills preferably with Word and Excel.
• Completion of a medical terminology course with a solid working knowledge
• Strong data entry skills necessary: type a minimum of 35 WPM required
• Excellent communication skills, both orally and written

Education, Licensure and/or Certifications

• High School graduate or equivalent.
• Pre-med, nursing, or healthcare-related degree preferred.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Movement within hospital complex environment
• Ability to write by hand, use keyboard and mouse extensively to perform general office functions
• Ability to communicate by speech and hearing continuously 
• Must have visual acuity near and far (20 inches to 20 feet), depth perception, field of vision, ability to focus on an object, ability to identify and distinguish colors
• Ability to sit and stand for extended periods of time
• Ability to occasionally stoop, kneel, crouch, and walk
• Ability to grasp, hold and pick up and reach with hands and arms
• Ability to occasionally lift and carry up to 25 pounds (periodic lifting of supplies or equipment)
• Ability to tolerate repetitive motions/movement for a significant time period.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

While performing the duties of this job, the employee is regularly exposed to hospital areas and general office environment. The work environment is a clean, well-lit, well-ventilated, and temperature controlled environment. The noise level in the work environment is usually moderate. The hours of duty are lengthy and irregular.