Scribe Plastic & Breast Surgery Day Shift PRN

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Job description

Overview:
This position serves as a representative of the physician. The position is responsible for documenting the physician-dictated patient history, physical examination, family, social, and past medical history. Documentation will also include procedure notes, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient's encounter. The essential functions of a scribe are:

a) A scribe will accompany the physician upon patient interview and examination.

b) A scribe will document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Scribes document physical examination findings and procedures as performed by the physician.

c) A scribe will document the results of laboratory and radiographic studies as dictated by the physician.

d) A scribe will document the correct time of patient care related activities, including physician to physician communication, family communication, and reexamination of a patient.

e) A scribe will not sign patient encounters. When the physician concludes the patient's encounter, the physician will review all documentation completed by the scribe. The physician will then make, if necessary, any amendments and sign the chart. Ultimately, the physician is responsible for documentation of the patient's encounter.

f) The scribe and physician will make "chart rounds" to review patient status, delays, and any other care related issues.

g) All patient care orders must be communicated by the physician and not scribe.

h) A scribe will not participate in any patient care and should refer all requests related to patient care to the assigned physician or nursing staff. This may include: transporting specimens, answering phones, assisting patients, and calling physicians.

Qualifications:
Minimum Education and Experience Requirements:

High school diploma or equivalent preferred, health classes: medical terminology and/or Anatomy and Physiology

Motor Vehicle Operator Designation:

Will not operate vehicles for an assigned business purpose

NOTE: A frequent driver is defined as one who uses his/her personal or Shands automobile a) at least once daily, b) at least five individual trips per week or c) drives, on average, over 150 miles per week in the performance of his/her job.

Licensure/Certification/Registration:

None

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