Medical Scribe - Internal Medicine - Good Shepherd Health Care

Employer paid benefits - Medical, Dental, and Vision

Wage scale - Min: $ 16.29  Max: $24.96

The duties of a Scribe are to perform all clerical and information technology functions for a clinician including documenting the clinician dictated patient history, physical examination, family history, social history, past medical history, procedures, lab results, radiographic impressions and any other information pertaining to the patient’s encounter in any clinical medical setting. The primary goal is to increase the efficiency and productivity of the clinician while enhancing the patient’s experience. Responsible for carrying out the mission, vision, and quality commitment of Good Shepherd Health Care System.

ESSENTIAL JOB FUNCTIONS:

• Accurately and thoroughly document medical visits and procedures as they are being performed by the clinician, including but not limited to:
• Patient medical history and physical exam,
• Procedures and treatments performed by the healthcare professionals, including nurses and physician assistants,
• Patient education and explanations of risks and benefits,
• Physician dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow up.
• Diagnostic findings, lab and test results, consultations with other providers, treatment course, discharge instructions and prescriptions.
• Spot inconsistencies or mistakes in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician 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.
• When the physician concludes the patient’s encounter, the clinician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The clinician is ultimately responsible for documentation of the patient’s encounter.
• All orders for patient care must be communicated by the physician and not the scribe.
• Professional, non-intrusive interaction with patients (the scribe does not directly assist with patient care), physicians, hospital staff and other co-workers.
• Compliance with hospital policies, including those relating to confidentiality of patient information.
• Other duties as assigned, including but not limited to, training other Scribes and staff.
• Position may require working variable hours including nights and weekends and within various specialties.

QUALIFICATIONS:

• Education - High School Diploma – Preferred
• Medical Scribe Certification - Required
• Other: Bilingual and/or English-Spanish speaking preferred.  Have the ability to work with a culturally diverse population. 
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EQUIPMENT AND TOOLS:

1)            Knowledge of computers, phones, and other office equipment.

2)            Knowledge of insurance regulations and medical terminology.

3)            Knowledge of filing procedures and record documentation.

4)            Bilingual, English/Spanish, is preferred, for customer service interpretation duties.

PERSONAL TRAITS, VALUES AND APTITUDES:    

Must be able to:

1)            Perform a variety of duties often changing from one to another without the loss of efficiency and composure.

2)            Demonstrate a positive, tactful, and harmonious attitude.

3)            Work independently.

4)            Recognize the rights and responsibilities of patient confidentiality.

WORKING CONDITIONS:

Inside environment protected from the weather, variable noise levels, occasionally subject to combative customers or verbal altercations with co-workers, subject to a rapid pace creating an unpredictable environment and subject to possible exposure to infection, contagious disease, or hazardous materials, just to name a few.

PHYSICAL DEMANDS:

Must be able to:

1)            Perceive the nature of sound by ear.

2)            Express or exchange ideas by means of spoken words.

3)            Extend arms and hands in any direction.

4)            Use of hands and fingers.

5)            Stoop, kneel, crouch, lift to 25 lbs., sit and/or stand for extended periods of time.

6)            Be self-motivated, dependable, neatly groomed and well organized.