Medical Scribe Ophthalmology

The Medical Scribe reflects the mission vision and values of NM adheres to the organizations Code of Ethics and Corporate Compliance Program and complies with all relevant policies procedures guidelines and all other regulatory and accreditation standards.

The Medical Scribe observes and accurately enters details and decisions from practitioner-patient encounters directly into the (EHR) electronic health record on behalf of the Provider. The Medical Scribe is present during clinical services and accurately documents information conversations and activity into the EHR in real time under the direct supervision of the Provider.

Responsibilities:

• Identifies/introduces self and role of Scribe to patient and/or family.
• Accompanies provider during patient interviews and examinations.
• Records pertinent positive and negative findings in patient history and physical examination including history of present illness past medical/surgical history social history review of systems medications allergies and family history.
• Records procedures Provider review of lab tests Provider review and impression of diagnostic images and/or review of official radiologist interpretations.
• May record time of patient care activities including Provider-to-Provider communicationfamily communication and re-examination of the patient.
• Assists with preparation of paperwork for disposition of patients from clinic setting.
• Helps increase Provider productivity and workflow by performing a variety of non-clinical tasks including:
  • Assisting the Provider(s) in navigating the EHR.
  • Researching information requested by the Provider.
  • May locate information for review (i.e. previous notes reports test results and laboratory results).
• Complies with all NMHC policies including those relating to confidentiality of patient information and all local State and Federal guidelines for documentation confidentiality and privacy (HIPAA).
• Ensures documentation in the EMR includes a statement that Document has been prepared at the direction and in conjunction with Provider along with the along with the Scribes name and title and that the Provider has included an attestation regarding the accuracy of the note.
• Generates and prints patient plan with scribe name on bottom.
• Scribes are prohibited from participating in any clinical care (must refer all requests related to patient care to the responsible Physician or Nursing staff) interjecting own feelings observations or impressions into the documentation dictating reports entering/writing prescriptions using Providers log-in or passwords or performing hospital duties.
• All other duties as assigned.

AA/EOE.

Qualifications :

Required:

• High School Diploma or equivalent.
• Basic medical terminology and coding knowledge.
• Strong written and verbal communication skills
• Ability to communicate and interact professionally with others.
• Strong attention to detail.
• Ability to actively listen and observe.
• Keyboard proficiency and the ability to operate a personal computer and related software applications.
• Ability to multi-task and work in a dynamic highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.
• Ability to problem solve under pressure.
• Understanding of and commitment to appropriate protection of confidential patient information.

Preferred:

• 2 years of experience working as a Medical Scribe Medical Scribe certification through a vocational school community college or university.

Additional Information :

Northwestern Medicine is an equal opportunity employer (disability VETS) and does not discriminate in hiring or employment on the basis of age sex race color religion national origin gender identity veteran status disability sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and at times internal transfers. If you are offered a position with us you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check.  Results are evaluated on a case-by-case basis and we follow all local state and federal laws including the Illinois Health Care Worker Background Check Act.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical emotional and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family. 

Remote Work :

No

Employment Type :

Full-time