Medical Scribe

Job Title:        Medical Scribe

Reports To:     Medical Director

Pay Range:     $23.00- $29.00 (Depends on Experience)

Location:         City Heights

Job Status/Hours:  Non-Exempt/Full Time

Summary

The Medical Scribe Professional is someone designed to train the individual in the field of medical scribing suited for La Maestra Community Health Centers. Performs all clerical and information technology functions for a physician in a specialty clinic setting, including primary responsibility for the operation of electronic health records. Primary goal is to increase the efficiency and productivity of the physician. This position will have no direct involvement in patient care.

Must be able to anticipate physician needs to facilitate the flow of clinic. Must be discreet and tactful in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important. Must be adaptable and versatile. Good attendance is an important element of this job.

Responsibilities

Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:

• Scribes are assigned to work with one provider.
• Scribes accompany the physician upon patient interview and examination.
• Scribes document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
• Scribes document physical examination findings and procedures as performed by the physician.
• Scribes document the results of laboratory and radiographic studies as dictated by the physician.
• Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
• When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign off the chart. The physician is ultimately responsible for documentation of the patient’s encounter.
• All orders for patient care must be communicated by the physician and not the Scribe.
• Medical knowledge and skills applied to a variety of healthcare departments found at La Maestra

The medical scribe will also take additional training as directed by La Maestra’s NextGen, Quality and Compliance departments.

• The medical scribe will report directly to the clinic site manager, department manager or medical director depending on the circumstances.
• Performs other duties as assigned. •Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert provider when Master IM is incomplete.

Patient Centered Medical Home Essential Responsibilities (Principals)

• Collaborate with individual patients, their personal physicians, and when appropriate the patient’s family to ensure accessible, comprehensive, compassionate, and culturally competent care
• Facilitate care by registries, information technology, health information exchange another means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
• Ensure all decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care.
• Continually strive to attend to each patients “whole person,” in the context of the patient’s personal and medical history and life circumstances, rather than focusing on a particular disease, organ, or system

Job Requirements Education: High School Diploma or GED

Certification: Medical Assistant Certificate preferred, Medical Scribe Certificate and current valid CPR card.

Experience: 1-2 years’ experience in a clinical office or hospital setting as a Medical Assistant preferred.

Require: Job knowledge of the behaviors, developmental stages, physical and emotional needs, life cycle changes, culture and comfort and care appropriate to the population served. Medical Terminology required.

• Medical terminology, HIPPA
• Anatomy and physiology
• Medical billing and coding basics
• Electronic medical records
• Elements of medical note-taking

Verbal and Written Skills to perform the job: Bilingual (English/Spanish) preferred. Familiarity with basic word processing, spreadsheet, and database applications. Accurate keyboarding skills.

Technical knowledge and skills required to perform the job: Excellent verbal, written and interpersonal communication skills and the demonstrated ability to work with diverse individuals and groups. Demonstrate high levels of self-initiation and direction. Knowledge of communities we serve. Knowledge and experience working in medical settings and interacting collaboratively with medical teams. Skill in analyzing situations and making timely decisions.

Physical and Mental Requirements: Work involves sitting, talking, hearing, using hands to handle, feel or operate objects, tools, or controls, and reaching with hands and arms. The employee may be required to push, pull, lift, and/or carry up to 20 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Quality Management

1.Display knowledge of normal signs of human development and ability to assess and provide age appropriate care.

2.Contribute to the success of the organization by participating in quality improvement activities

Customer Relations

1.Respond promptly and with caring actions to patients and employees. Acknowledge psychosocial, spiritual and cultural beliefs and honor these beliefs.

2.Maintain professional working relationships with all levels of staff, clients and the public.

3.Be part of a team and cooperate in accomplishing department goals and objectives

4.Interacts and communicates in a manner to reflect an understanding of the patient’s age, culture, state of health, and level of comprehension

Safety

1.Maintain current knowledge of policies and procedures as they relate to safe work practices.

2.Follow all safety procedures and report unsafe conditions.

3.Use appropriate body mechanics to ensure an injury free environment.

4.Be familiar with location of nearest fire extinguisher and emergency exits.

5.Follow all infection control procedures including blood-borne pathogen protocols

HIPAA/Compliance

1.Maintain privacy of all patient, employee and volunteer information and access such information only on a need to know basis for business purposes.

2.Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent or unlawful behavior or activity.

Work Environment

1.The noise level in the work environment is usually moderate

2.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

General Requirements

Pre-employment requirements include I-9 verification, physical examination, background and reference check results, completed employment application, new hire orientation attendance.

OSHA Compliance

1.Comply with all regulations and required schedules regarding OSHA training.

Employee Physical Compliance

1.Required physical to be performed annually.

Policies and Procedures Compliance

1.Responsible for following all La Maestra Family Clinic policies and procedures.

Meal Period Compliance (Non-exempt employees only.)

1.Punch out before 5 hours from the start of shift for meal periods.

Sexual Harassment Training (Management employees only.)

1.Comply with all regulations and required schedules regarding sexual harassment training.

Acknowledgement

La Maestra Community Health Centers is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation or belief.

I acknowledge that I have read and understand the attached job description. My signature below certifies that I am able to perform the essential duties and responsibilities of this position. I have also discussed any accommodations that I feel I might need to allow me to perform these essential functions. I agree to abide by all administrative and medical policies and protocols of La Maestra Community Health Centers.