Medical Scribe

The Medical Scribe provides real-time documentation support to physicians, advanced practice providers, and other authorized clinical providers in a Federally Qualified Health Center (FQHC) environment. The Medical Scribe accurately documents patient encounters in the electronic health record (EHR) at the direction of the provider, allowing the provider to focus more fully on patient care.This position supports accurate, timely, and complete clinical documentation while maintaining compliance with HIPAA, organizational policies, documentation standards, and applicable federal and state requirements. The Medical Scribe does not independently provide patient care, make clinical decisions, or perform duties outside the authorized scope of the position.Essential Duties and ResponsibilitiesAccompany assigned providers during patient encounters and document the encounter in the EHR in real time or as directed by the provider.Accurately document patient histories, review of systems, physical examination findings, assessments, treatment plans, procedures, and other components of the encounter as communicated by the provider.Enter documentation accurately and timely while maintaining the integrity of the medical record.Assist with documenting information related to medications, diagnoses, referrals, laboratory and imaging results, preventive services, and follow-up plans as directed by the provider.Retrieve and organize relevant clinical information, including previous progress notes, test results, consultation reports, and other records needed by the provider.Prepare encounter documentation for provider review, correction, authentication, and signature.Make documentation corrections or updates only at the direction of the provider and in accordance with organizational policy.Support complete and accurate documentation necessary for continuity of care, quality reporting, coding, billing, and regulatory requirements.Maintain awareness of documentation requirements associated with FQHC operations, including preventive care, chronic disease management, population health initiatives, and applicable quality measures.Protect the confidentiality, privacy, and security of patient information in accordance with HIPAA, organizational policy, and applicable federal and state law.Follow established procedures for accessing, documenting, storing, and transmitting protected health information.Communicate professionally and effectively with providers, nurses, medical assistants, behavioral health staff, care coordinators, front office staff, and other members of the interdisciplinary care team.Participate in required orientation, compliance training, HIPAA training, safety training, competency assessments, and other organizational education.Ensure that the provider has signed off encounters, reviewed labs/procedures, paperwork and answered messages in the appropriate timeComply with organizational policies related to infection prevention, patient safety, workplace conduct, information security, and confidentiality.Support the organization’s mission to provide accessible, high-quality healthcare to medically underserved populations.Perform other related duties as assigned that are consistent with the scope and responsibilities of the position.Scope of Practice and Role LimitationsThe Medical Scribe is a documentation support position and does not independently perform clinical functions. The Medical Scribe may not:Independently assess, diagnose, or treat patients.Provide medical advice or patient education unless specifically directed and permitted by organizational policy.Independently enter, initiate, modify, or discontinue medication, laboratory, imaging, referral, or treatment orders.Select diagnoses, determine medical necessities, or make independent coding decisions.Perform clinical procedures unless separately trained, qualified, authorized, or function under another approved job role.Sign or authenticate provider documentation.Document information that was not observed, communicated, or approved by the provider.Exercise independent clinical judgment on behalf of a provider.The provider remains responsible for reviewing, editing as necessary, authenticating, and signing all documentation completed with the assistance of the Medical Scribe.Minimum QualificationsHigh school diploma or GED required.Medical terminology coursework, training, or demonstrated knowledge required.Successful completion of organization-required Medical Scribe training and competency validation.Strong typing, spelling, grammar, listening, and documentation skills.Ability to accurately capture clinical information in a fast-paced healthcare environment.Strong attention to detail and organizational skills.Ability to maintain strict confidentiality of patient and employee information.Proficiency with computers and ability to learn and effectively use the organization’s EHR and other electronic systems.Ability to work effectively with diverse patient populations and interdisciplinary healthcare teams.Preferred QualificationsMedical Scribe certification or formal scribe training preferred.CMA/RMA with at least 1 year of experience preferredPrevious medical scribe or clinical documentation experience preferred.Previous experience in a community health center, primary care, family medicine setting preferred.Familiarity with EHR systems, medical terminology and documentation standardsKnowledge of healthcare compliance, HIPAA, and patient privacy requirements preferred.Knowledge, Skills, and AbilitiesKnowledge of medical terminology and clinical documentation practices.Strong written communication and active listening skills.Ability to document information accurately while following the provider’s direction.Ability to work efficiently in a high-volume outpatient environment.Ability to prioritize multiple tasks and maintain accuracy under time constraints.Strong professional judgment and discretion when handling confidential information.Ability to work collaboratively as part of an interdisciplinary care team.Ability to communicate respectfully with patients from diverse cultural, socioeconomic, and educational backgrounds.Ability to maintain professional boundaries and comply with established organizational policies and procedures.Compliance ResponsibilitiesThe Medical Scribe is expected to comply with all applicable organizational, federal, and state requirements, including:HIPAA privacy and security requirements.Organizational compliance and code of conduct standards.Documentation integrity and medical record requirements.Fraud, waste, and abuse prevention standards.OSHA and workplace safety requirements.Applicable HRSA and FQHC compliance expectations.Organizational infection prevention and patient safety requirements.Employees are expected to promptly report suspected compliance, privacy, safety, or documentation concerns through established organizational channels.Physical RequirementsThe position requires the ability to sit, stand, walk, and use a computer for extended periods. The Medical Scribe may be required to move between examination rooms, clinical workstations, and other areas of the health center throughout the workday. Will be expected to travel to different clinics sites as needed. #J-18808-Ljbffr Sandhills Medical