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Medical Scribe ID-11713

 
Job Description
SUMMARY: Works under general supervision to record, facilitate and ensure an accurate and complete medical record for each patient, including gathering data and coordinating tests and orders. No medical decision making is performed. 

Role will work / be medical transcriptionist for 12 hours a week at our Plastic Surgery Clinic. 

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ESSENTIAL FUNCTIONS 
• Records details of history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies. 
• Record details of physical exam, including pertinent positives and negatives, noted abnormalities and patient general condition. 
• Submit orders as desired by medical provider and check constantly for results of those orders. 
• Troubleshoot for causes and solutions of any orders that are not completed in a timely fashion or if results are incomplete. 
• Coordinates tests, orders, and results to ensure all health information is recorded accurately and is ready for access by the medical provider. 
• Lists all proper diagnoses as well as any discharge/follow-up instructions and prescriptions as dictated by the physician or medical provider. 
• Assist in disposition of patient, whether discharged or admitted including discharge instructions, admission orders and prescription forms. 
• Ensures provider closes encounters and accepts transcription. 
• Performs other duties as assigned. 

MINIMUM QUALIFICATIONS 
EDUCATION/EXPERIENCE: High School diploma. 1 year of experience working with medical terminology in a medical environment. 

Knowledge, Skills, & Abilities 
• Work requires accuracy in all phases of work performed. 
• Work requires working knowledge of medical terminology. 
• Work requires ability to recognize physical exam process and to record exam details. 
• Work requires legible handwriting skills. 
• Work requires ability to quickly learn new applications. 
• Work requires good communication skills and the ability to coordinate and cooperate with staff and providers. 
• Work requires good organizational skills. 
• Work requires ability to maintain confidentiality and privacy considerations for patients and families according to HIPAA. 
The following is the acronym, "PACT", and is fundamental to all non clinical positions at UT Southwestern Medical Center: 
• P-Problem Solving: Employees take ownership in solving problems effectively, efficiently, and to the satisfaction of customers, or managers. They show initiative in addressing areas of concern before they become problems. 
• A-Ability, Attitude and Accountability: Employees exhibit ability to perform their job and conduct themselves in a professional and positive manner reflecting a professional environment readily assuming obligations in a dependable and reliable manner. 
• C-Communication, Contribution, and Collaboration: Who are our Customers? Anyone who requests our help, needs our work product, or receives our services. Employees focus on customer service with creative solutions while improving the customer experience through clear, courteous, and timely delivery and communication. Sharing ideas with others helps expand our contribution to department goals. 
• T-Teamwork: Employees work to contribute to the department's success by supporting co-workers, promoting excellence in work product and customer service, and in maintaining a satisfying, caring environment for each other. 
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