Medical Scribe

Description

CORE VALUES

The core values of Community Health Center of Southeast Kansas (CHC/SEK) are dignity and stewardship. Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of the Center's resources.

GENERAL DESCRIPTION

The scribe position is part of the clinical team. This position is responsible for accurately and thoroughly documenting medical information into the electronic medical record (EMR) during a patient's encounters with a provider. This position should have a comprehensive knowledge of the EMR in order to provide consistent documentation and identify errors in medical documentation. The scribe should anticipate the provider's needs in order to facilitate the flow of patients through the clinic.

Requirements

ESSENTIAL DUTIES

• Provides positive first impression, through words and tone, to patients, visitors, and employees presenting to the clinic areas.
• Act as an extension of the provider performing documentation.
• Accurately and thoroughly document medical visits and procedures as they are being performed by the provider, including but not limited to:
• medical history and physical exam,
• clinical data, lab, x-ray, or other test results,
• procedures and treatment,
• provider interpretations of results,
• medication and prescription updates,
• patient education,
• patient/family follow-up and self-care,
• Responsible for scheduling patient appointments.
• Enter lab information and follow up with patient on results.
• On occasion may sort and scan medical documentation into the electronic medical record.
• Collect the data for Meaningful Use, UDS reporting, PCMH, clinic performance improvement activities, and other program accreditations.
• Performing scribe duties should not distract the provider from patient care.
• Collaborate with clinic support staff to assure the patient's electronic record is complete.
• Documentation should be reviewed and approved by the provider.
• Comply with specific standards that apply to the legal and ethical requirements for preparing medical documents and protecting patient's health information.

The essential functions listed are not an exhaustive list of every task the employee is required to complete. Employees are expected to perform all other duties as assigned.

QUALIFICATIONS

• High school diploma required.
• Computer literate and able to type 50 words per minute.
• Experience in a clinic or healthcare setting including familiarity with medical terms, preferred.
• Able to communicate with others to effectively convey information.
• Social and cultural sensitivity appropriate to ethnically and economically diverse patients and employee base.

WORKING CONDITIONS

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, peripheral vision, depth perception and ability to adjust focus. The noise level in the work environment is usually moderate.