Medical Scribe

The Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. The Medical Scribe must be able to anticipate physician needs to facilitate the flow of clinic. 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. The Medical Scribe be adaptable and versatile since s/he will be responsible for many tasks. **EXPECTATIONS:** - Arrives on time and adheres to set schedule - Provides prompt medical support; promotes a smooth patient flow; collects and records data accurately - Participates with community-oriented activities and staff - Consistently and openly communicates with supervisor and all staff - Works flexible or extended hours where necessary - Participates in health center in-services, by listening and respecting others’ ideas - Demonstrates awareness of, and compliance with, organizational mission and objective of Camarena Health - Abides by Rules of Confidentiality - Use of professionalism and best efforts in the position **DUTIES and RESPONSIBILITES** 1. **Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:** 1. Patient medical history and physical exam 2. Procedures and treatments performed by healthcare professionals, including nurses and physician assistants 3. Patient education and explanations of risks and benefits 4. Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up 5. Prepare referral letters as directed by the physician **2. Dictation/Faxing/Phone calls and Clerical Tasks, including but not limited to:** 1. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record 2. Medical Scribes also ensure that letters are mailed or faxed daily to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. 3. The Medical Scribe may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned. **3. Oversees mistakes and inconsistencies in medical documentation, including but not limited to:** 1. Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors. 2. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. 3. Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential. 4. **Data Collect, organize and catalog, including but not limited to:** 1. Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. 2. The Medical Scribe assists in developing and maintaining systems to track patient follow up and compliance. 5. **Trainings, Information Technology, HIPAA:** 1. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. 2. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar. 6. **QUALIFIC…