Job Description

Job Description

Job Description

The Scribe assists the team in a professional manner in the health clinic setting. Responsibilities include handling time-consuming clerical responsibilities for providers during patient encounters. Scribes accompany providers and directly observe patient encounters. They accurately document the events and decision-making in a manner that results in appropriate medical charting. Scribes also complete clerical activities necessary to assist with processing of orders for tests and medications. By accomplishing the time-consuming clerical duties that otherwise would be assigned to a provider, Scribes enable providers to spend more time with individual patients and increase the overall flow of patients in the department. Scribes with a CMA certification may be asked to perform additional duties within the scope of their certification.

Duties and Responsibilities

1. The Staff Scribe performs the following duties as assigned.

1. Accurate, timely charting of patient encounters, including but not limited to patient history, physical exams, diagnostic findings, lab and test results, consultations with other providers, emergency department treatment course, diagnoses, discharge instructions and prescriptions.
2. Professional, non-intrusive interaction with patients (the scribe does not directly assist with patient care), physicians, hospital staff and other co-workers.
3. Compliance with Clinic policies, including those relating to confidentiality of patient information.
4. Other duties as assigned, including but not limited to training other Scribes and staff.

2. May perform duties with scope of CMA certification, as needed

1. Maintains clinical expertise and competency as well as demonstrates thorough knowledge of procedures to deliver quality health care.

3. Fulfills administrative duties.

1. Assists in maintaining an efficient, safe, secure, orderly, and aseptic environment of care for all patients and employees.
2. Is familiar with and abides by OSHA Standards, Hazardous Materials, Universal Precautions, use of personal protective equipment, Evacuation, Fire, Disaster, and Safety Plans.

4. Performs all other duties as assigned.

Knowledge, Skills and Abilities

Required

• Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.
• Strong written and verbal communication skills
• Ability to actively listen.
• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
• Ability to spell proofread and edits written text.
• Keyboard proficiency (approximately 60 words/minute).
• Ability to operate a personal computer and related software applications.
• Strong attention to detail.
• Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.
• Ability to coordinate multiple projects and patients.
• Ability to problem solve under pressure.
• Ability to communicate and interact professionally with others.
• Understanding of and commitment to appropriate protection of confidential patient information.
• Commitment to high professional ethical standards
• Ability to read and comprehend medical instructions, short correspondence, and memos
• Knowledge of medical terminology and appropriate abbreviations
• Ability to document, with clarity, all information relevant to a patient’s needs
• Ability to effectively present information in small group situations to patients, Clinic staff, and the general public.
• Ability to use office equipment including but not limited to computers, fax machines, telephones and copiers
• Ability to prepare statistical and administrative reports
• Ability to quickly gain specific knowledge of the Clinic’s current operational protocols

Preferred

• Spanish speaking and writing skills

Credentials and Experience

Required

• Current Cardiopulmonary Resuscitation (CPR) Certification
• Certified Medical Assistant (CMA)

Preferred

• One (1) year of practice experience in a clinic office setting.

Education

• Minimum high school diploma/GED.

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