· Accurately and thoroughly document medical visits and procedures as they are being performed by the provider, including but not limited to:

· Patient medical history and physical exam,

· Procedures and treatments performed

· Patient education and explanations of risks and benefits.

· Provider-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up

· Prepare referral letters as directed by the provider

· Dictation/faxing/phone calls and clerical tasks.

· Prepare referral letters as directed by the provider, via dictation or summary of the medical record.

· Ensure that letters are mailed or faxed on a daily basis to all providers involved in a patient’s care, and with all copies of pertinent reports or tests attached.

· Research contact information for referring providers, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

· Identify mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.

· Ensure all addenda must be signed off by a provider.

· Ensure that all clinical data, lab or other test results, the interpretation of the results by the provider are recorded accurately in the medical record.

· Alert provider when chart is incomplete.

· Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

· collect, organize and catalog data for provider quality reporting system and other quality improvement efforts and format for submission

· assist in developing and maintaining systems to track patient follow up and compliance

· Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the provider’s medical documents for accuracy, spelling, punctuation, and grammar.

· Fill in as the provider’s medical assistant if needed.

· All other duties as assigned