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The scribe is a person who is present during a provider's performance of clinical services, and who documents in the medical record on behalf of the provider, what was said during the course of the service, as well as, the activities performed by the provider.
1. Maintains an environment of safety for patients, self and others.
2. Enter data into the electronic medical record, ensuring the EMR is complete and accurate.
3. Gather and document clinical information from other current or historical records under the direction of the provider.
4. Perform other duties that improve the efficiency of the provider such as, assisting with medication reconciliation, documenting procedures, and providing communication assistance (message to other providers, scanning, printing or copying medical records).
5. Must complete annual HIPPA, patient confidentiality and scribe training requirements and sign a confidentiality agreement.
● High School diploma or GED.
● Prefer CMA
Professional Experience Requirements:
● Medical terminology education, CNA, CMA or other medical experience preferred.
Knowledge/Skills/and Abilities Requirements:
This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.