Performs both scribe and medical assistant responsibilities, encompassing clinical, technical and administrative duties which support patient care and clinical operations. Works to facilitate patient flow and ensure an accurate and complete medical record for each patient. Responsibilities may vary daily depending on physician and patient needs.
- Accompany physician into the patient examination room in order to transcribe and document the physician’s encounter with the patient and others present.
- Accurately and thoroughly document medical visits and procedures as they are being performed by the physician including but not limited to:
- Patient medical history and physician exam
- Procedures and treatments performed by healthcare professionals
- Patient education and explanations of risks and benefits
- Physician diagnoses, prescriptions and instructions for patient or family members for self-care and follow up
- Proper diagnoses and symptoms as well as follow up instructions and prescriptions as specified by the physician
- Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
- Adhere to company policies and scribe documentation and attestation requirements.
- May also transcribe dictated physician notes into electronic health records system.
- Collaborate with other medical office staff to ensure a positive patient experience.
- Other duties as assigned.
- Verifies patient information by interviewing patient, recording medical history and confirming purpose of visit.
- Prepares patients for examination by performing preliminary physical tests; taking blood pressure, weight, and temperature; reporting patient history summary.
- Secures patient information by completing and safeguarding medical records, completing diagnostic coding and procedure coding and keeping patient information confidential.
- Completes specimen labeling and routing, ancillary referrals, documentation, supply and pharmaceutical ordering, consent forms and waivers.
- Maintains up-to-date resource materials (contract, ancillary and vendor grids; eligibility rosters, formularies).
- Maintains organized system for timely call backs, related documentation and follow-through.
- Accurately and thoroughly records patient concerns, phone triage and medication refills in medical record.
- Reviews appointment schedules in advance to anticipate problems with patient flow. Prior to appointments, reviews medical records to ensure most recent dictation and lab results are filed.
- Communicates effectively with front office staff regarding same day appointments, changes to schedule and related issues.
- Assists with effective medical records management by accurately completing requests for charts, and out guide cards and returning medical records to file room expeditiously.
- Maintains supply stock in exam rooms and overall inventory of supplies and pharmaceuticals.
- Maintains logs and records as required by OSHA/CLIA regulations.
- Performs other indirect patient services and clerical duties to facilitate the overall management of patient.
- Demonstrates competency in carrying out prescribed treatment plan and monitoring patient’s condition.
- Demonstrates competency in performing EKG, holter, treadmill, peak flow, pulse oximetry, spirometry, ear lavage, vitals, collecting and preparing lab specimens, in-office laboratory tests, sterilizing equipment and instruments, administering injections and medications, drawing blood, handling and disposing of contaminated supplies, removing sutures and changing dressings.
Demonstrates competency in assisting with procedures by well executed arrangement of exam room, equipment and instruments. Demonstrates thorough understanding of OSHA/CLIA guidelines regarding universal precautions, bio hazardous safety and infection control.
Education: High school diploma or equivalent.
Certification: Certification not required, but certificate from an accredited Medical Assistant (MA) program is required.
Minimum Experience: Six months as a Medical Scribe or six months related experience and/or training, or equivalent combination of education and experience.
Prefer one year of experience as Medical Assistant in primary care setting and experience working with patient electronic health record systems.
Knowledge and Skills:
- Knowledge of medical terminology, anatomy, physiology, diagnostic procedures, pharmacology and treatment assessments to the extent required to understand and accurate transcribe during patient visits and from dictated notes
- Understanding of physical exam process and ability to record exam details
- Computer proficiency and ability to quickly learn new applications
- Proficient in typing and good spelling, punctuation, grammar and oral communication
- Must be able to listen to complex medical information and summarize in a clear, complete and concise fashion
- Organizational skills with focus on tracking patient care and improving patient flow
- Professional demeanor and recognition of privacy considerations for patients and families
- Must be able to act calmly and effectively in a busy or stressful situation
- Must be able to establish and maintain effective working relationships with medical staff and peers
Here is my Answer: How to Find The Direct Patient Care Experience
You have many options.
It can be as simple as volunteering in your local community hospital, in a retirement center, working overseas, at a blood center, a children's center, The Special Olympics or a special needs summer camps, etc. etc. Most hospitals need volunteers and have a department dedicated to this. It is a perfect place to start.
That’s exactly what I did when I started in patient transport. I merely walked through the front door of the University Hospital, gave my biggest smile and asked the front desk staff where I could find information about volunteer opportunities. They gave me a vest, a badge and I was making my first patient transport the following day.
Later that year, I took a short walk to the student clinic and once again threw a big smile on my face and asked if there were positions for students interested in healthcare. They introduced me to "Jennifer," a senior pre-med student working in the clinic as an assistant phlebotomist. Jennifer let me shadow her for the day. She introduced me to staff all over the hospital. I can't tell you how much I respected her and wanted to be like her.
It was because of Jennifer that I landed my first paid position in the clinic as a medical records clerk making $4.25 an hour. My job included filing and retrieving records (it was the pre-digital era), so I got to explore the various specialty clinics and collect and distribute medical records to all the providers in every specialty. I met just about everyone in the clinic, including my first physician assistant.
The following year Jennifer graduated and passed her phlebotomy position on to me. They trained me to do work in the laboratory and perform blood draws (without a certificate). Upon graduation, they provided me with an official certification, and I went on to work for the University Hospital and the Puget Sound Blood Center as a lead technician.
I Volunteered Everywhere I could:
- During my senior year, I spent the summer working at a special needs youth summer camp.
- After graduation, and after I returned home from work, I took evening classes for three months to get my EMT certification.
- I volunteered at a homeless shelter.
- I was applying for a 3-month internship to work in Chicago Catholic Youth Ministries when I was accepted into PA school.
I am not trying to pat myself on the back. What I am trying to do is to show you that to make it anywhere in life, you have to get out and just do it.
Opportunities rarely come knocking at your door, but there are opportunities everywhere. If you are short on opportunities in your area, then go to where the opportunities are. I am on the board of our Physician Assistants For Global Health organization, and there are endless opportunities to work overseas, and you don't need any patient care experience to get started.
But Stephen, I have kids, family to support, school and a part-time job!
Trust me, as a father of two with an extremely busy schedule I understand.
If you have kids, family, a part-time job, school, a family member to care for, a pet gerbil that requires a lot of time and attention, etc. etc. it simply means you have to dig a bit deeper and get a little more creative. It may mean taking classes at night to get that certification you may need, cutting back on hours at work, teaming up with your partner or friends to get creative with child care, you may have to take a massive leap of faith and quit your current job entirely.
Nobody said it was going to be easy. You just never give up, no matter how hard the challenges are, observe this world with a healthy dose of skepticism and don't just follow the herd as somebody else might do.
Once you are on target, you will find this isn’t "work" at all; it is a joy to help other people. It will open your mind as well as your heart, and you will become a better person along the way.
- Send out a request to your Facebook or Linkedin network
- Search global health opportunities
- Call your local health center
- or homeless shelter
- or children's hospital
- or veterans association
- or senior living center
You get the point.
Say you are willing to work for free… and do an awesome job, and you will also have the glowing letters of recommendation you need!
And, to top it off, you will feel good about yourself, you will develop the skills you need to love and care for another human being, and this is what matters most if you are to be successful in life and as a PA.
I hope this helps,