Medical Scribe

Medical Scribe

It is the responsibility of the medical scribe to document information gathered during clinic visits in real time under the direction of the clinician in adherence with local, state, and federal guidelines for documentation in the electronic health record.

Essential Functions:

Documentation

• The primary role of the medical scribe is to assist the clinician with documentation in chart notes during patient encounters (in clinic, telemedicine, or virtual). Documentation includes but is not limited to medical history, subjective and objective information, review of systems, physical exam, assessments, treatment plans, and procedures notes. Transcription of diagnostics results may also be included in documentation if requested by the clinician.

Assistance with Ordering of Diagnostics/Referrals

• In addition, the medical scribe will, based on the instructions of the clinician, prepare orders such as labs, diagnostic imaging, in office procedures, point of care tests, preventative health screenings, and referrals for the clinician to sign.

Coordination of Care Assistance

• Scribes act as an additional line of communication between the providers and other ancillary team members or clinic resources (case management, integrated behavioral health, AOD, nutrition, referral coordinators, call center/patient service representatives, MA/nursing, etc.), either verbally or electronically, in order to ensure patient receives comprehensive services in a timely manner.

Clerical Duties

• Scribes may be assigned clerical task assigned by their supervisor that include but are not limited to manual data mining from the EHR, chart audits, assisting with development of and participating in medically related quality improvement projects, distribution of workflow training material, and document management.

Additional Duties

• Active participation in team huddles

• Active participation in quality improvement initiatives

• Active participation in multidisciplinary committees and workgroups

• Assist with the training of new staff in collaboration with leadership and preceptors/mentors

• Active collaboration with clinical and non-clinical staff to ensure care is proactive, coordinated, and timely

• Other duties as assigned

Education/Experience Required:

• Diploma or GED equivalent

• Some College

• Diploma or GED equivalent

• Some College

• Minimum typing speed of 40 WPM

• Strong English writing skills including grammar, format structuring, and spelling

• Ability to identify issues, think critically, and problem solve independently

• Ability to work effectively in a team setting

• Exposure to a medical related field, typically gained with at least 6 months of:

• Previous employment as a medical scribe

• Employment in a clinic, hospital, or other medical setting

• Volunteer experience in a clinic, hospital, or other medical setting

• Volunteer experience in community programs focused on health outcomes

• Clinical research experience

• Relevant coursework (including but not limited to medical terminology, anatomy, physiology, biology, microbiology, pharmacology)

Preferred

• Experience navigating an electronic health record

• Proficiency in Microsoft programs (Word, Excel, PowerPoint)

• MSCAT certification or completion of an accredited scribe certification program

• Medical assistant certification

• Ability to dedicate themselves to the role for at least one year.

Reasonable Accommodations

One Community Health endorses and supports the Americans with Disabilities Act of 1990 (ADA) and the California Fair Employment and Housing Act (FEHA) and is committed to providing reasonable accommodations to qualified individuals with disabilities who are applicants or employees who need accommodations. If you require and accommodation due to a disability to complete this application or you are experiencing difficulty submitting your application, please contact us at ochhumanresources@onecommunityhealth.com

Our Benefits

For more information on the comprehensive benefits we provide, please visit: https://onecommunityhealth.com/careers/benefits/