Medical Scribe

Medical Scribe

The Redding Rancheria is seeking a Medical Scribe. The preferred schedule for this position is 4, 10 hour shifts.

Basic Job Purpose/Function:

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, sending referrals, ordering labs, ordering x-rays, 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.

Requirements/Minimum Qualifications:

1. One year of experience in a healthcare field preferred or minimum 2 year of college education with Medical Terminology, Anatomy, and Physiology coursework/degree.
2. Must be fingerprinted and pass background check.
3. Must pass pre-employment drug screening.
4. Indian preference.

Essential Job Duties:

1. 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.
2. Accompanies the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
3. Documents any procedures performed by the clinician or nurses and printing the consent forms prior to the procedure, on the electronic medical chart.
4. 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.
5. 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.
6. The Medical Scribe is to order labs and order x-rays, with knowing how to add the patient to the x-ray schedule.
7. Transcribe referrals during the visit while sending it to the correct specialty.
8. Generating notes, excusal letters, and any other forms the clinician requires; in so being able to navigate the document library.
9. The Medical Scribe is to know how to schedule a patient for future visits.
10. The Medical Scribe is to be able to look up insurance, in assisting the front staff.
11. The Medical Scribe is to aide in management of QIP measures.
12. Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
13. Ensures medical record compliance by self-documentation attestation.
14. Other duties as assigned.