Scribe; work closely with board-certified Emergency Physicians and Physician Assistants to create and maintain accurate documentation of patient encounters using Nextgen Electronic Medical Records (EMR). Nextgen EMR documentation includes: history of present illness, review of systems, detailed physical exams, ordering and recording results of radiology and lab testing, writing prescriptions, referrals, and selecting final diagnoses with proper ICD-9 code, patient education, work/school notes, and referrals.
Secondary responsibilities include; Triage patients: obtaining vital signs, acquiring a simple history of illness, identifying any home medications and recording in the chart along with past medical history and allergies, and determining the acuity of the visit. Discharging patients: review of discharge instructions, review of patient information, problem solving any issues the patient may have in implementing his/her treatment plan, discontinuation of any IV access established during the visit and dressing application.
Special Assignment as Scribe Trainer; work closely with the scribe manager to teach new hires the process and importance of creating and maintaining accurate chart notes using Nextgen EMR through a four week training program.