Medical Scribe - Health System
Fort Collins, CO
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 2 months, or longer! ***
Medical Scribe Job Summary:
Medical Scribe Background:
- 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.
- Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies in to the medical record system.
- Accompanies physician into patient examination area in order to transcribe a history and physical examination as given by the patient and physician or medical provider.
- Records details of physical exam, including pertinent positive and negative noted abnormalities and patients’ general condition in the medical record system.
- Validates test results are received and reviewed during patient visit as directed by medical provider.
- Coordinates tests, orders, and results to ensure all health information is recorded accurately and ready for access by the medical provider.
- Lists all proper diagnoses as well and any discharge/follow up instructions and prescriptions as dictated by the physician or medical provider.
- Ensures that provider has signed their own dictation and super-bill.
- Requires High school diploma/GED or equivalent; Associates or Bachelor degree strongly preferred
- 2 years of experience in acute care or multi-specialty clinic using electronic medical record software or maintaining medical records