Medical Scribe (Children's Health Center)

Job Description

POSITION SUMMARY : The Medical Scribe is trained in medical documentation and assists a physician or medical provider throughout their shift with transcribing clinical notes, entering orders, and referrals under the direction from the providers. The primary goal of a Medical Scribe is to increase the efficiency and productivity of the medical provider they are working with. The Medical Scribe allows the provider to focus on what is most important, the patient. Medical Scribe duties include performing all clerical and information technology functions for a medical provider in a clinic setting. This includes primary responsibility of the operation of the electronic health record system. Anticipating provider needs to facilitate the flow of visit is critical for incumbent success. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe.

ESSENTIAL JOB FUNCTIONS : The list that follows is not intended as a comprehensive list, but rather to provide a representative summary of the major duties and responsibilities. Incumbent(s) may not be required to perform all duties listed, and may be required to perform additional, position-specific tasks.

• Accompany medical provider into the patient examination room to transcribe a history and physical exam, and document accurately the medical provider's encounter with the patient and others present.
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the medical provider.
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
• Document any procedures performed by the medical provider.
• Dictation / faxing / phone calls and clerical tasks, including but not limited to prepare referral letters as directed by the medical provider, via dictation or summary of the medical record, research contact information for referring providers, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Verify accuracy of medical documentation and correct the information in order to reduce errors; ensures that all clinical data, lab or other test results, the interpretation of the results by the medical provider are recorded accurately in the medical record, alerting the medical provider when chart is incomplete.
• Other duties as assigned.

Experience and Skills

EDUCATION, EXPERIENCE, CERTIFICATIONS, AND LICENSES :

Native Preference. Northern Valley Indian Health provides Native Preference in hiring practices for qualified Native applicants, in accordance with its policy. NVIH is also an Equal Opportunity and At Will Employer.

Job Benefits

Medical, Dental, Vision, Life Insurance, 401K available