Medical Assistant/Medical Scribe

$41,600 - $51,958/Yr

Stony Brook University - Stony Brook, NY

Part-time,Full-time - Entry Level

Stony Brook, NY

Educational Services

About the position

The Medical Assistant/Medical Scribe plays a crucial role in documenting and charting medical data during provider-patient encounters. This position involves following the provider into patient rooms to accurately record relevant notes and medical data that would typically be documented by the provider themselves. The role is essential for ensuring that all clinical data is captured accurately and efficiently, contributing to the overall quality of patient care.

Responsibilities

• Place patients in examination rooms and document medications, vitals, and the main reason for the visit for the physician.
• Record vital signs including height, weight, blood pressure, pulse, and temperature.
• Enter patient information into the Electronic Medical Record (EMR).
• Assist the physician with special procedures and examinations as needed.
• Obtain previous test results from outside labs, radiology, and doctor's offices.
• Explain treatment procedures, medications, diets, and physician's instructions to patients clearly and effectively.
• Clean and sterilize instruments and dispose of contaminated supplies.
• Maintain an adequate inventory of medical supplies in each exam room.
• Ensure the cleanliness of each exam room and prep rooms after each patient and for specific procedures as needed.
• Order medical supplies as needed.
• Ensure HIPAA guidelines are followed at all times.
• Create a concise narrative of the patient's story (History of Present Illness) based on provider and patient interaction.
• Perform administrative duties when needed, such as answering phones and scheduling appointments.
• Write referral letters for doctors or other types of correspondence.
• Spot mistakes or inconsistencies in medical documentation and correct them as necessary, with physician sign-off.
• Ensure all clinical data, lab results, and physician interpretations are recorded accurately in the medical record.
• Alert the physician when the chart is incomplete.
• Proofread and edit all physician's medical documents for accuracy, spelling, punctuation, and grammar.

Requirements

• At least 1 year of prior experience working as a Medical Assistant in a busy physician practice.
• Proficient in typing, spelling, punctuation, grammar, and oral communication.
• Ability to listen to complex medical information and summarize it clearly and concisely.
• Excellent English composition skills to generate professional, polished writing at a high rate of production.
• Certification as a Medical Assistant preferred.
• Knowledge of medical terminology.
• Knowledge of clerical and clinical practices and procedures.
• Computer and/or EMR experience.