The primary responsibilities of the Medical Scribe to document all relevant dictated or written information for the treatment of patients. Medical Scribes will be responsible for clearly recording each patient's symptoms, history, physical exam, and documenting the diagnosis as well as treatment plans abiding by all local, state, and federal guidelines for documentation into electronic medical records. The Medical Scribe is not a direct patient care role.
Essential Functions of the Job:
The Medical Scribe assists the Clinician with documentation of each patient's electronic health record during patient visits.
Accompanies the clinician into the patient examination area in order to transcribe a history and physical examination.
Under the direction of the clinician, transcribes patient orders, including laboratory tests, radiology tests, referrals etc.
Documents any procedures performed by the clinician or nurses, on the electronic health record.
Transcribes any consultation or discussions with family and/or the clinician.
Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
Assists the clinician and support staff with paperwork, telephone calls, faxing, and chart abstraction.
At the end of the day or shift, provides the scribed documentation for the clinician to review to ensure all events were recorded accurately.
Make recommendations for continued process improvement to the Scribe Manager.
Prohibited Scope of Service:
Medications: A scribe cannot prescribe medications. Scribes cannot stop, start, or make any changes to any medications.
Orders: A scribe cannot order any in-house medications that are injected, ingested, or inhaled into the body including nebulizer treatments. The expectation being immunizations.
Patient Care: The scribe is not directly involved with patient care; however, he/she may be asked to give patient paperwork during visit or discuss discharge instructions with a patient. The scribes direct interactions with patients is limited.
General Documentation: A scribe cannot document any of his/her personal objective findings or be involved in any of the medical decision-making. A scribe cannot act independently; instead, he/she must simply document the physician's dictation and or/activities during the visit.
Additional Duties and Responsibilities:
Maintains confidentiality of all patient and employee information and adheres to all HIPAA requirements.
Informs supervisor of matters of general interest and problem areas determined or discovered.
Attends all SYHealth mandatory meetings and other meetings as requested.
Attends team meetings as needed.
Understands and adheres to all SYHealth policies and procedures.
Adheres to and consistently demonstrates SYHealth's Core Values of Respect, Excellence, Empowerment and Integrity.
Education Required (Minimum level of education):
Bachelor's Degree in medical field preferred. High School required with relevant additional
college level courses.
Experience Required (Minimum level of experience):
6 months to a 1 year of Medical Scribe experience required.
Experience with medical terminology and/or medical coding.
ACMSS Certification is preferred
Verbal and Written Skills Required to Perform the Job:
Strong written and verbal skills in English language required.
Proficient in the Arabic language is required.
Physical Activities:Prolonged periods of sitting, walking and standing. Possible local driving and occasional travel required.
Working Traits:Organizational ability and ability to follow directives. Technical Knowledge and Skills Required to Perform the Job:
Excellent oral and written communication.
Advanced computer skills.
Experience with EHR's, preferably NextGen and/or EPIC.
San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family.
The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 92,000 patients through a vast and integrated network of 34 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees.
Apply today and become a part of our mission-driven team!
San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to reace, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
San Ysidro Health Center