Senior Clinical Documentation Specialist

Role – Medical Scribe Trainee

Main role of the scribe is to document doctor patient encounter in a real time .

Documentation for some of the best US Hospitals across multiple specialties

1.Attend all the training Modules as per the set instructions and timelines. Successfully complete the entire course and clear the performance checkpoints to attain a Client Ready status.

2.Able to go live with the assigned provider and Scribe independently.

3.The Medical Scribe Trainee drives service delivery excellence and customer satisfaction for their assigned client through strong charting skills, communication, and very high standards of work ethics.

4.Accurately and thoroughly document medical visits and procedures as they are being performed by the physician,including but not limited to:

- Patient medical history and physical exam,

- Procedures and treatments performed by healthcare professionals, including nurses and

- physician assistants.

- Patient education and explanations of risks and benefits.

- Physician-dictated diagnoses, prescriptions and instructions for patient or family members for

- self-care and follow-up

- Prepare referral letters as directed by the physician

- Pend orders.

5.Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.

6.Attend training on varied subjects such as information technology, legal, HIPAA and regulatory compliance.Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

7.Keep supervisor up to date on availability and notify Supervisor of schedule changes with assigned provider(s)

8.All other task/projects as assigned