Department/Unit:
Emergency Medicine General
Work Shift:
Per Diem (United States of America)
Salary Range:
$46,215.00 - $60,080.00
The Medical Scribe provides scribe services in an Emergency Department at the direction of a Physician or Advanced Practice Provider (Nurse Practitioner or Physician Assistant) allowing the clinician to spend more time with the patient, work more productively, and produce accurate and thorough documentation in real-time. A Medical Scribe does not act independently but documents the clinician's previously determined dictation and/or activities in the electronic medical record (EMR).
Essential Duties and Responsibilities- Work side-by-side with a provider as they see patients.
- Provide real-time charting by shadowing the provider throughout their schedule and performs a variety of tasks including recording the patient's history and chief complaints, transcribing the physical exam, ordering x-rays, recording diagnostic test results, and coordinating with departmental resources about tests, orders, radiology, and results.
- Accompany the provider into the patient examination room to transcribe a history and physical exam, and document accurately the provider encounter with the patient and detailed information including any procedures performed by the provider.
- List all proper diagnoses and symptoms and follow up instructions and prescriptions as dictated by the provider.
- Record details of physical exam, including pertinent positives and negatives, noting abnormalities and patient general condition
- Add proper documentation-inserts as required.
- Adheres to HIPPA laws
- Transcribe and facilitate patient orders including laboratory tests, radiology tests, medications and referrals; submits orders as desired by medical provider; and checks constantly for results of those orders.
Qualifications- High School Diploma/G.E.D. - required
- Successful completion of either Anatomy & Physiology (or equivalent) or Medical Terminology coursework at the undergraduate level or above - preferred
- Experience in a direct patient care environment - preferred
- Basic understanding of medical terminology and general medical knowledge
- Strong communication skills, written and verbal.
- Excellent listening and note-taking skills.
- Detail oriented with proven ability to work effectively under conditions requiring accuracy.
- Excellent organizational and time management skills
- Ability to remain calm in a fast paced, at times stressful environment.
- Computer proficiency
Equivalent combination of relevant education and experience may be substituted as appropriate.
Physical Demands- Standing - Constantly
- Walking - Constantly
- Sitting - Rarely
- Lifting - Frequently
- Carrying - Frequently
- Pushing - Occasionally
- Pulling - Occasionally
- Climbing - Occasionally
- Balancing - Occasionally
- Stooping - Frequently
- Kneeling - Frequently
- Crouching - Frequently
- Crawling - Occasionally
- Reaching - Frequently
- Handling - Frequently
- Grasping - Frequently
- Feeling - Constantly
- Talking - Constantly
- Hearing - Constantly
- Repetitive Motions - Constantly
- Eye/Hand/Foot Coordination - Constantly
Working Conditions- Extreme cold - Rarely
- Extreme heat - Rarely
- Humidity - Rarely
- Wet - Rarely
- Noise - Constantly
- Hazards - Frequently
- Temperature Change - Rarely
- Atmospheric Conditions - Rarely
- Vibration - Rarely
Thank you for your interest in Albany Medical Center!
Albany Medical Center is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:
Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
Thank you for your interest in Albany Med Health System!
Albany Med Health System is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:
Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.