Billings Clinic Medical Scribe in Billings / Billings, Montana
Job Description: Responsible for assisting providers with patient care by documenting history and vital signs. Accompanies provider is room and documents clinical note, laboratory results, prescription refills, procedures, billing information and any other documentation as directed by the provider.
Essential Job Functions
• Accompany provider in room during patient visit.
• Scribe document in Cerner to include history of present illness, review of systems, physical
• exam findings, diagnostic assessment, and plan of care.
• Refill any patient prescriptions as directed by the provider.
• Enter orders for procedures or labs, as directed by the provider.
• Enter billing information as determined by the type of office visit.
• Treat all information and data utilized in the scope of the scribe position with complete confidentiality and security in compliance with governing HIPAA regulations.
• Schedule follow-up appointments/procedures, as indicated by the provider.
• Communicate and interact professionally with others.
• Maintain accurate patient records.
• Responsible for following OSHA regulations.
• Maintains patient, employee and clinic confidentiality.