Justine Mastroluca

Emergency Room Medical Scribe/Charge Scribe

Mountain View Scribe Services Group LLC

Grand Terrace

01.2020 - Current

Maintained confidentiality of all patient information according to HIPAA regulations.
Observed examinations and procedures performed by providers to document findings accurately in the EMR system.
Train all new scribe trainees and on call for trainees
Assist in shift coverage
Audit patient charts from other scribes on staff
Scanned documents such as x-rays and laboratory results into the patient's electronic chart.
Compiled referrals for specialist appointments with appropriate documentation attached.
Communicated effectively with staff members across the ER department
Obtained and Input details about patient histories, physical examinations, medications and other information into physical or electronic charts.
Followed clinicians throughout shift in high-volume, busy environments.
Demonstrated knowledge of terminology for multiple medical specialties, consistently seeking ongoing training to expand and maintain knowledge base.
Used Cerner medical record software every day and developed advanced skills.
Prepared and sent patient documentation to provider for review and approval via authentication of detailed data entry and facility-specific procedures.
Captured and transcribed medical record documentation with electronic medical record applications.
Monitored duration of basic lab results and screening procedures.
Informed doctor of urgent patient needs per nursing progress notes.
Reviewed and edited transcribed reports or dictated material for spelling, grammar and proper medical terminology.
Translated medical jargon and abbreviations into expanded forms to promote accuracy of patient and health care facility records.
Assisted in preparing for procedures by gathering supplies and equipment needed.
Created accurate reports on patient visits including chief complaint, history, physical exam findings, assessment and planning.
Used Cerner medical record software every day and developed advanced skills.
Documented and initiated tests, scan and other orders.