MEDICAL SCRIBE (Kosse, TX)

Limestone Medical Center's Kosse Community Health Clinic has an opening for a full time Medical Scribe (preferred Medical Assistant) to join our team.  We offer a competitive benefit package available after 90 days of full time employment.

Job Summary:

A scribe’s core responsibility is to capture accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner. Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider.

ESSENTIAL FUNCTIONS:

• Assisting the provider in navigating the EHR.
• Responding to various messages as directed by the provider.
• Locating information for review (i.e., previous notes, reports, test results, and laboratory results)
• Entering information into the EHR as directed by the provider.
• Researching information requested by the provider.

• Accompany the provider upon patient interview and examination.
• Document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Scribe will document physical examination findings and procedures as performed by the physician.
• Document the results of laboratory and radiographic studies as dictated by the physician.
• Document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
• When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.
• The physician and the Scribe will make “chart rounds” bi-weekly to review chart status and delays.

• All orders for patient care must be communicated by the physician and not the Scribe.

• Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc.
• Treat all information, data and training materials utilized in the scope of the Scribe position with complete confidentiality and security.
• Understand and adhere to the attached policy and agreement regarding scribe documentation.

ADDITIONAL DUTIES AND RESPONSIBILITIES:

• Maintain and demonstrate an understanding of the team approach to patient care and documentation.
• Complete and present the medical record in collaboration with the supervising physician.
• Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.
• Participate in ongoing educational opportunities as offered.
• Attend regularly scheduled staff meetings.
• Be responsive to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician, and staff.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:

• Work will require both standing and sitting for long periods of time.
• May occasionally lift up to 30 pounds.
• Requires manual dexterity sufficient to operate a keyboard, calculator, telephone, copier and other office equipment as necessary.
• Must be able to see and hear.
• Must be comfortable and composed in a direct patient care setting.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Medical terminology and technical spelling.
• Basic Anatomy.
• Basic coding.
• Demonstrate the knowledge and skills necessary to document essential elements of a provider-patient encounter as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
• Demonstrate the ability to maintain patient confidentiality and privacy in accordance with governing HIPAA regulations.
• Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation and/or electronic information related to patient care.
• Computer aptitude, including functions of the HER.
• Knowledge and understanding of Physician Quality Reporting System, Meaningful Use and GPRO as outlined by the Centers for Medicare and Medicaid Services.
• General knowledge of the roles and responsibilities of medical personnel.

EDUCATION AND EXPERIENCE:

• Requires high school diploma or equivalent.
• Requires at least one year of experience in a hospital or clinic setting.