Medical Scribe (Urgent Care)

Job Description

Job Description

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JOB SUMMARY Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity 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.
• Accompany the clinician into the patient examination area to transcribe a history and physical examination as given by the patient and physician.
• Document 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 uses these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reporting.
• 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 to get the patient’s workup complete so that the clinician is able to make his or her decisions regarding that patient.
• Orders in-house testing, Immunizations, lab testing, diagnostic testing along with generating referrals.
• Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
• Other duties as assigned.

Optional Trainable Skills

A Scribe can be trained to handle Patient Portal tasks for your assigned provider and chart abstraction.

KNOWLEDGE, SKILLS, AND ABILITIES

EDUCATION & EXPERIENCE

PREFERRED QUALIFICATIONS

BENEFITS

Shasta Community Health Center is an Equal Opportunity Employer