JOB SUMMARY:
The Medical Scribe is an individual trained in medical documentation who will assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the provider. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients. The Medical Scribe will follow all local, state and federal guidelines regarding documentation into the electronic health record. 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 desk staff.
ESSENTIAL FUNCTIONS:
- The primary role of the Medical Scribe is to assist the provider with documentation of patient's medical chart during his or her visit.
- Accompanies the provider into the patient examination room in order to transcribe the patient history and physical examination as given by the patient and provider.
- Documents any procedures performed by the provider or nurses, on the electronic medical chart.
- Is an expert in the use of various templates and documentation techniques available in the EHR (Electronic Health Record) 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 provider.
- Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the medical scribe continuously checks on the progress of this data in order to get the patients workup complete, so the provider is able to make decisions regarding the patient.
- Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
- Performs other duties as assigned.
EDUCATION AND EXPERIENCE:
- High school graduate or equivalent.
- Medical Scribe Certification and Aptitude Test (MSCAT) certification after 200 hours on the clinic floor, preferred.
QUALIFICATIONS
- Previous experience working in an outpatient clinic or doctors office.
- Medical Terminology, Anatomy and Physiology Coursework.
- Ability to type 45-60 WPM.
- Must have excellent Customer Service skills, positive attitude, and be a team player.
- Maintain confidentiality of all patients, and employee information.
- Must pass a re-employment drug screen, physical and background investigation.
- Effective verbal, listening and communication skills.
- Must possess current CPR certification.
SPECIAL QUALIFICATIONS: All employees must be sensitive to the needs of the Native American community, demonstrate a deep understanding and respect for the diverse cultural heritage, traditions and historical context of the Native American community.
PHYSICAL REQUIREMENTS:
While performing the duties of this job, the employee is regularly required to have manual dexterity; reach with hands and arms, stoop, or kneel; and talk and hear within normal, range. The employee is frequently required to stand, walk, sit, climb, or balance. The employee must regularly be able to lift and/or move up to 25 pounds.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Frequent possible exposure to bloodborne/airborne pathogens or infectious materials.
- Noise level ranges from quiet to moderate.
How to Apply
Submit your application to Sonoma County Indian Health Project, Inc.
Attention: Human Resources Department
Address: 144 Stony Point Road, Room 2209, Santa Rosa, CA 95401
Email: [email protected] Fax: (707) 526-1016
Application Form: Available online at www.scihp.org/human-resources
When applying under Indian Preference, please include valid documentation of eligibility with your application materials.
Skills Required
- High school graduate or equivalent
- Medical Scribe Certification and Aptitude Test (MSCAT) after 200 hours on the clinic floor
- Previous experience working in an outpatient clinic or doctors office
- Medical Terminology, Anatomy and Physiology coursework
- Ability to type 45-60 WPM
- Excellent customer service skills, positive attitude, and team player
- Maintain confidentiality of all patient and employee information (HIPAA compliance)
- Must pass a re-employment drug screen, physical and background investigation
- Effective verbal, listening and communication skills
- Must possess current CPR certification
- Sensitivity to and understanding of Native American cultural heritage and traditions
What We Do
Established in 1971, Sonoma County Indian Health Project, Inc. (SCIHP) provides comprehensive health care services, including medical, dental, behavioral health, and pharmacy, to the Indian communities of Sonoma County and others.
