Medical Scribe

  • Grand Rapids, MI
  • Mary Free Bed Rehabilitation Hospital
  • Medical Group Admin
  • Full-Time - Days - 8a-5p
  • Administrative
  • Posted: February 20, 2020
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We have the great privilege of helping patients and families re-build their lives. It’s extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients “Ask for Mary,” they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them.

Mary Free Bed is a not-for-profit, nationally accredited, rehabilitation hospital with 167 inpatient beds – 119 acute and 48 sub-acute. There are numerous outpatient programs as well as home and community services. With the most comprehensive rehabilitation services in Michigan and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. 

Mission Statement
Restoring hope and freedom through rehabilitation.

Diversity and Inclusion 
Mary Free Bed values diversity and inclusion among patients, families and staff. We strive to hire people who reflect the communities we serve. Our employees will serve all patients, families and each other with dignity and respect.

Essential Job Responsibilities:

  • Accompany the physician into the patient examination area in order to transcribe findings in real time as the provider evaluates the patient.
  • Documents the history of the patient’s chief complaint as given by the patient and by provider.
  • Documents the review of systems (ROS) and physical examination as given by patient and performed by provider.
  • Documents patient orders, including laboratory tests, imaging tests, etc. as dictated by the provider
  • Completes the procedure note on behalf of the provider, as directed.
  • Looks up pertinent past medical records at the direction of the provider.
  • Enters documentation on patient progress as directed by provider.
  • Make and receive phone calls on behalf of provider as needed.
  • Inform provider when diagnostic studies are completed, prepare for review, and document in EMR.
  • Lists proper diagnosis as well as any follow-up instructions and prescriptions, as dictated by the provider.
  • Reviews the record and verifies that the documentation requirements have been met for the designated code assigned by the provider.
  • Scribes document the correct time of patient care related activities, including provider to provider communication, family communication and re-examination of the patient.
  • The provider will review all documentation completed by the scribe, make any necessary amendments, and sign the chart. The provider is ultimately responsible for documentation of the patient’s care.
  • The provider and the scribe will make “chart rounds” to review patient status, delays, and any other care-related issues.
  • All orders for patient care must be communicated by the provider and not the scribe.
  • Scribes do not participate in any patient related care and should refer all requests related to patient care to the responsible provider or nursing staff; including, but not limited to, transporting specimens, answering phones, calling providers, etc.
  • Follows documentation compliance standards.
  • Assures that the Electronic Health Record is complete and that all pertinent documentation requirements are met, including the diagnosis, disposition and patient education
  • Interventions. Ensures the provider reviews the Electronic Health Record for accuracy. Ensures provider signs, under the provider’s profile, for each encounter.
  • Work under pressure, within time constraints. Must be able to act calmly and effectively in a busy or stressful situation
  • Develop and maintain a mutually respectful working relationship with all providers.
  • Available for provider concerns and questions and is ready to assist in documentation at all times.
  • Other duties as assigned

Additional Responsibilities:

  • Maintain and demonstrate an understanding of the team approach to patient care and documentation.
  • Completion and presentation of the medical record in collaboration with the supervising provider.
  • Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.
  • Participate in ongoing educational opportunities as offered by Mary Free Bed.
  • Be responsive to improvement opportunities in a positive manner.
  • Communicate in a professional and respectful manner to the supervising provider, ancillary hospital staff.

Essential Job Qualifications (Knowledge, Education, and Training Requirements):

  •  High School Diploma or GED
  •  1-2 years of experience preferred in medical setting
  •  Medical Scribe experience preferred or prior health care experience
  •  Current Basic Life Support (BLS) certification
  • Physical Demands/Work Environment:  The work environment described here are representative of those an employee will encounter while working as a RN at Mary Free Bed.  The ability to perform these tasks are required in order to provide the necessary patient care required by MFB patients:
  • Required to stand, sit, talk, type, read, and hear
  • Required to use hands and arms to handle, feel, carry and work 
  • Required to frequently stand, walk, bend, kneel, and rise from a kneeling position while performing patient care.
  • Required to be independently mobile, with frequent bending, and reaching overhead, for activities such as positioning and transferring of patients and equipment.
  • Must be able to exert 20 to 35 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects(*).  
  • Due to possible exposure to blood-borne pathogens and hazardous materials, must be able to understand and follow department policies related to employee safety.
  • Must be competent with computer systems for the purpose of documenting patient care.
  • Demonstrates the knowledge and skills necessary to document patient care as dictated by a provider in a legible and clear manner, following all local, state, and federal guidelines for documentation including:
  • Medical terminology
  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • Principles of billing, coding, and reimbursement
  • Electronic medical record (EMR) navigation and functionality, as appropriate based on job description
  • Computerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission
  • The amount of training required in these areas will vary depending upon the person’s past training and experience.

 

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.

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