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Scribe
Oklahoma City, OKFull-timeSeen 1w agoSeen in employer's feed 1 day ago
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Job overview
The Scribe accompanies providers during patient examinations and documents encounters in the medical chart. The role includes recording patient histories, physical exams, diagnostic results, diagnoses, procedures, consultations, and follow-up instructions under provider guidance. The scribe also monitors the availability of ordered data so providers can complete patient workups and make treatment decisions.
Skills & qualifications
Skills
Qualifications
Full job description
It's more than a career, it's a calling.
OK-SSM Health Medical Group Oklahoma City 608
Worker Type:
Regular
Job Summary:
Accompanies provider into the patient examination room to document the provider's encounter with the patient. Collaborates with the provider to document the patient history, physical exam, results of diagnostic testing, and diagnosis and disposition.
Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES
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Assist providers with documentation of each patient's medical chart during encounters. Accompany the provider into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
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Document all procedures performed by the physician, physician extenders, or nurses, on the medical chart.
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Transcribe consultations or discussions with family and/or the patient's private physician or the on-call physician.
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Complete the patient's charts by transcribing results of any labs, x-rays, or other evaluations. Continuously check the progress of data availability for orders, to ensure the patient's workup is complete so that the provider is able to make treatment decisions regarding that patient.
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List all proper diagnoses as well as any discharge/follow-up instructions and prescriptions, under guidance of the physician.
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May occasionally assist with some patient-related duties.
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Works in a constant state of alertness and safe manner.
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Performs other duties as assigned.
EDUCATION
- High School diploma/GED or 10 years of work experience
EXPERIENCE
- No experience required
PHYSICAL REQUIREMENTS
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Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
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Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
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Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
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Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
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Frequent keyboard use/data entry.
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Occasional bending, stooping, kneeling, squatting, twisting and gripping.
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Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
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Rare climbing.
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS
- None
Work Shift:
Day Shift (United States of America)
Job Type:
Employee
Department:
6350000040 SAPO PULM CLINIC
Scheduled Weekly Hours:
40
SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law. Click here to learn more. (https://www.ssmhealth.com/privacy-notices-terms-of-use/non-discrimination?\_ga=2.205881493.704955970.1667719643-240470506.1667719643)