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Medical Scribe

Company: Neighborhood Healthcare
Location: Escondido
Posted on: May 14, 2022

Job Description:

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Job Type
Full-time
Description
Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.
As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 77k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.
Summary
Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency, productivity and accuracy of the physician. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state and federal guidelines for documentation into the electronic health record system. The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front office staff.
JOB DUTIES AND RESPONSIBILITIES


  • The primary role of the Medical Scribe is to assist the clinician with documentation of each patient's medical chart during his or her visit.
  • Accompanies the clinician into the patient examination area, either in person or telephonically in order to transcribe a history and physical examination as given by the patient and physician.
  • Documents any procedures performed by the clinician or nurses, on the electronic medical chart.
  • Is an expert in the use of various templates and documentation techniques available in the EHR system, and use these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
  • Transcribes any consultations or discussions with family members and/or the clinician.
  • Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient's workup complete so that the clinician is able to make his or her decisions regarding that patient.
  • Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
  • Other duties as assigned.

    PHYSICAL DEMANDS

    • STANDING/WALKING: Up to 50% of the workday consists of stand/walking on tile and cement floors while performing scribe duties.
    • SITTING: Up to 50% of the workday may be spent sitting operating an Ergotron or Laptop.
    • LIFTING: Lifting may include up to 10 lbs. in moving equipment. 5% of the day involves lifting requiring a full range of motion.
    • CARRYING: Up to 25% of the day may include carrying objects weighing up to 10 lbs., this may include carrying charts, equipment, and resource materials.
    • PUSHING/PULLING: Up to 5% of the day may require pushing or pulling equipment, drawers, carts etc.
    • CLIMBING: No more than 1% of the time may include climbing one flight of stairs.
    • STOOPING/KNEELING: Up to 5% of the workday are spent stooping or kneeling to open drawers and gathering equipment.
    • BENDING/CROUCHING: Up to 25% of the workday may be spent in bending at the waist picking up charts and assisting the clinician with procedures.
    • REACHING/STRETCHING: Up to 3% of the time may require reaching or stretching to retrieve equipment/materials on shelves.
    • HAND/WRIST: Hand and wrist movement is required 75% of the workday in holding charts and supplies.
    • FINGERING: Up to 75% of the workday involves data entry, receiving and sending messages, chart abstraction, and general data entry.
    • FEELING: Normal tactile feeling is required to perform all job duties, including taking pulses.
    • TWISTING: Up to 5% of the day may be required in retrieving supplies or equipment.
    • TALKING: Average ability is required in communicating with patients, staff, and outside agencies.
    • HEARING: Average ability is required for the ability to clearly hear clinician and patient comments.
    • SEEING: Average ability is required to read and follow instructions and assisting clinical team.

      Requirements
      KNOWLEDGE, SKILLS, AND ABILITIES

      • Ability to read, write, understand and spell English and medical terminology correctly.
      • Basic Computer proficiency in Windows environment.
      • Typing 55 WPM.

        EDUCATION & EXPERIENCE

        • High school diploma or equivalent.
        • Obtain Medical Scribe Certification and Aptitude Test (MSCAT) certification after 200 hours on the clinical floor.

          PREFERRED Qualifications

          • Previous experience working in an outpatient clinic or doctor's office.
          • Medical Transcriptionist experience.
          • Typing 55 WPM or greater.
          • Medical Terminology, Anatomy and Physiology Coursework.

            PERSONAL BEHAVIOR

            • Displays ability to develop rapport across a broad range of personalities.
            • Displays cheerful demeanor and makes positive comments when on duty.
            • Refrains from participation in harmful gossip, dysfunctional group interactions and divisive behavior.
            • Displays courteous and professional behavior in all interactions with the public.
            • Works cooperatively with other staff members.
            • Displays flexibility in accepting, changing or carrying out assignments.
            • Adheres to dress code expectations, including fragrance-free requirements.
            • Displays sensitivity in a multicultural environment.

              Neighborhood Healthcare requires employees to be fully vaccinated (including a booster dose) against COVID-1 and demonstrate proof of vaccination/booster upon hire or receive approval for an exemption based on a medical reason, disability or religious belief. Proof of booster dose will be contingent upon booster eligibility.

Keywords: Neighborhood Healthcare, Escondido , Medical Scribe, Healthcare , Escondido, California

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