Medical Scribe - Bilingual, English/Spanish (Full-Time)

MISSION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION SUMMARY

The Medical Scribe assists the provider with medical documentation to increase the efficiency and productivity of the clinical visit. The Medical Scribe documents each patient's symptoms, history (HPI), physical exam and diagnosis in the electronic health record (EHR), and dictated or written information for the treatment of patients. The Medical Scribe does not provide direct patient care and follows local, state, and federal guidelines in an interdependent role in assisting clinical and front office staff. The bilingual Medical Scribe will communicate, translate and interpret with patients and providers in Spanish.

DUTIES AND RESPONSIBILITIES

To be performed in accordance with RFHN Policies and Procedures

• Reviews charts with the provider prior to patient visits to identify preventive care to be addressed during the visit.
• Documents the history and physical exam findings during the patient visit as communicated in the patient and provider encounter.
• Documents all procedures performed by the provider or clinical staff in the EHR.
• Uses templates and work-flow documentation tools effectively to ensure that encounters are completely documented as well as enabling the collection of data for statistical reports.
• Transcribes the consultations and discussions between family members and the provider.
• Enters the results of labs, x-rays, or other evaluations into the EHR.
• Monitors the progress to completion of the patient's work-up data to support the provider's decisions regarding the treatment plan.
• Documents confirmed diagnoses as well as follow-up instructions and pends orders for diagnostic imaging, labs, referrals, and prescriptions, as dictated by the clinician.
• Facilitates the consistent and complete use of PHQ9 or PHQA, drug alcohol tobacco brief screen, and any other screenings assigned to medical scribes.
• Facilitates medication reconciliation.
• Distributes "Reach out and Read" books.
• Completes documentation on the patient record by end of regular scheduled work hours. Assesses for barriers to obtaining services (transportation, access, etc.) and follows up on what resources the patient might need to obtain screening.
• Adheres to the scope of the role of medical scribe when documenting the patient's response to the provider's questions:

a. Collects patient HPI data only while the provider is in the room, except for screening tools.

b. Documents patient history as obtained by the provider; history is not taken independently.

c. Documents the review of systems independently and records patient responses to provider questions.

• Completes documentation of the physical exam, assessment and plan with the direction of the provider. The medical scribe role responsibilities do not include or permit medical decision-making.
• Seeks clarification on details of the physical exam as needed and verifies they are choosing the correct assessment as it relates to lab, diagnostic tests, referrals, procedures, and other orders. They will review the chart completely with the provider. Ensures that correct billing codes are applied before submission of the record.
• Addresses immunization and health maintenance screening gaps in care under the direction of the provider.
• Medical scribes may not interpret lab results or explain lab results to a patient.
• Completes medication reconciliation and may prepare orders for the provider to send to the pharmacy.
• Schedules follow-up, lab, imaging, and vaccine appointments for patients at the request of the provider.
• Drafts letters for patients under the express direction and on behalf of the provider for work/school excuse, surgery, and dental clearance, etc.
• Responds to in-basket tasks including refill requests, lab results follow-up, and patient calls only at the request of the provider and only in the capacity to order requested labs, referrals, pass along instructions, or schedule lab or follow-up appointments per the provider.
• Translates or interprets for patients or patient's family members present.
• Other duties as assigned and requested.