Summary/Objective:

The Medical Scribe/Medical Assistant is a hybrid role position responsible for supporting healthcare providers through accurate clinical documentation and maintaining timely, complete patient records within the Electronic Health Record (EHR) system. Primary scribe responsibilities include accompanying providers during patient encounters, documenting patient histories, symptoms, physical examination findings, assessments, and treatment plans, and updating medical records under provider supervision. The employee will also assist with chart preparation, gathering relevant patient information, and completing follow-up documentation as directed by the provider. As needed, the employee will perform medical assistant duties, including preparing patients and examination rooms, obtaining and documenting patients’ histories, assisting with clinical procedures, and maintaining clinical supplies and equipment. The ideal candidate is detail-oriented, adaptable, and capable of supporting efficient clinic operations while maintaining patient confidentiality, ensuring documentation accuracy, and delivering excellent patient care.

Essential Functions:

• Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Accurately document patient histories, physical examination findings, diagnoses, treatment plans, procedures, and other clinically relevant information in the EMR while accompanying providers during patient encounters and under provider supervision.
• Review, retrieve, and prepare pertinent medical records, diagnostic imaging, laboratory results, and prior clinical documentation for provider evaluation.
• Maintain and update patient records and complete clinical documentation and billing-related activities in accordance with provider instructions and organizational standards.
• Prepare patients for examinations and procedures by obtaining and documenting vital signs, medical histories, and other required clinical information.
• Assist providers with patient care activities, including clinical procedures, phlebotomy, post-operative care, and telephone triage.
• Prepare platelet-rich plasma (PRP), dextrose prolotherapy solutions, and other biologic treatments in accordance with established protocols and provider directives.
• Assist with the sterile preparation and harvesting of bone marrow and adipose tissue grafts, as trained, authorized, and within scope of practice.
• Ensure all required diagnostic test results, medical records, and supporting documentation are obtained and available prior to patient appointments.
• Enter and verify patient information in ultrasound equipment and ensure all studies are accurately recorded and archived within the PACS system.
• Maintain examination rooms in a clean, organized, and fully stocked condition to support safe, efficient, and effective patient care.
• Monitor and maintain inventory levels of clinical supplies, medications, and injectable products; track expiration dates, remove expired items, and coordinate replenishment as necessary.
• Handle, store, and dispose of biohazardous materials in compliance with OSHA regulations and established clinical policies and procedures.
• Respond to incoming telephone calls and perform assigned administrative and clerical duties in a professional and timely manner.
• Provide operational support at multiple clinic locations and travel between offices as required to meet organizational needs.
• Promote efficient clinic operations by exercising sound judgment, working independently when appropriate, and collaborating effectively with providers, staff, and management.