Medical Scribe
Scribe America
Livingston, TX
12.2023 - Current
- Obtained accurate medical histories from patients and documented them into the Paragon system.
- Performed data entry of patient information, including demographics, vital signs, lab results, and other pertinent information.
- Verified accuracy of dictated reports prior to release for physician review.
- Maintained confidentiality of all patient information according to HIPAA regulations.
- Observed examinations and procedures performed by physicians to document findings accurately in the Paragon system.
- Prepared charts for upcoming appointments by retrieving relevant medical history from previous visits.
- Compiled referrals for specialist appointments with appropriate documentation attached.
- Communicated effectively with staff members across departments to ensure that all necessary paperwork is completed correctly and promptly.
- Demonstrated proficiency in use of software programs utilized within healthcare setting.
- 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 Paragon medical record software every day and developed advanced skills.
- Prepared and sent patient documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
- Reviewed patient records to code and abstract information on medical diagnosis and procedures.
- Translated medical jargon and short-hand data into correct terminology.
- Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
- Shadowed physicians while doing medical procedures.
