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Clinical Scribe

FirstHealth of the Carolinas
Pinehurst

Job Description

Reviews vital signs and general health information in patient chart. Accompanies provider(s) into patient examination room to accurately and efficiently document the encounter including HPI, physical exam, and assessment and plan as presented verbatim by provider. As requested by the provider document lab and radiology findings. Document procedures, consults and discussions. Enter verbal and written orders for provider signature. Locate past medical history, previous notes, and recent studies at the provider's request. As part of the patient visit, present for the providers review and update patient record in regard to pain assessment, problem list, quality measures, and a current reconciled medication sheet. Maintain exam rooms for patient visits in regard to HIPAA guidelines and adapt same HIPAA principles to chart documentation and exposure as well as discussing PHI in front of anyone other than patient and or those authorized by said patient. Enter accurate and concise data into the EMR. Processes patient referrals for tests and referrals to specialists per clinic workflow.

Qualifications: Must be certified or registered CMA, RMA, LPN, RN. Experience in working in a medical related field where medical terminology and electronic medical records are in use

Employment Type

Full Time: 36 or more hrs/wk

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