Medical Scribe

Website La Maestra Family Health Center

Job Title: Medical Scribe

Reports To: Medical Scribe Director

Location: National City & El Cajon

Summary
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.

Other Responsibilities

  • 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 and other 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 required: Medical Assistant Certificate preferred.

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.

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.