Medical Scribe - Oncology - Medical Oncology

A scribe specializes in documenting the patient encounter from start to finish. He/she acts as an efficiency partner to the healthcare provider going into patient examination rooms in order to transcribe the patient’s history, physical exam findings, consultations, labs, X-rays, and follow-up care, as stated by the provider, directly into the medical record.

Duties and Responsibilities

• Accompany providers during patient visits to assist in documenting the provider assessment and exam

• Become an expert in how to appropriately document patient history, physical exams, assessments, diagnostic results, medical procedures, treatment plans, and medical opinions of consultants

• Interact with your provider to capture accurate diagnoses, pharmacy prescriptions and patient follow-up instructions

• Assist providers in obtaining lab and radiology results to help guide their patient care

• Gain knowledge on how to discover past history and test results on patients which are critical in driving medical decisions by your provider

• Understand the flow of patient encounters in your facility to assist the care team in making patient visits as efficient as possible.  Follow the progress of labs, imaging studies, and other real time patient data

• Perform a variety of other non-clinical tasks dependent on your provider’s requests

• Understand basic documentation requirements for the World Health Organization’s International Classification of Diseases (ICD-10)

• Ensure compliance on all national and local patient privacy laws including HIPAA and HITECH

• Adhere to medical facility’s compliance requirements and ScribeAmerica’s company policies and procedures

• Ability to travel between local hospitals and local medical facilities depending on the program