Medical Scribe ~ Utica Park Clinic

Utica Park Clinic (UPC) is part of Ardent Health Services, based in Nashville, Tennessee. Ardent makes considerable investments in people, technology, facilities, and communities, producing high quality care and extraordinary results.

Utica Park Clinic is the physician’s group of Hillcrest HealthCare System. With over 60 locations throughout northeastern Oklahoma, most patients enjoy the convenience of a location that is close to home. UPC patients have consistently given top ratings (98% patient satisfaction scores) for the quality of care they receive. When choosing a healthcare provider, you can be confident that you'll find a good match at Utica Park Clinic.

• 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.
• Be responsive to improvement opportunities in a positive manner
• Communicate in a professional and respectful manner to the supervising physician and ancillary hospital staff
• Assigned to work with one physician per shift.
• Accompany the physician 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.
• 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” to review patient status, delays, and any other care-related issues.
• 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.

Education

Minimum:

• High school graduate
• Completion of a medical terminology course or one year medical terminology experience in a clinical setting

Preferred:

• Healthcare student - physician, nursing, physician assistant, healthcare administration, etc.
• College level education including health or medical related courses
• Upper level knowledge of medical terminology
• Upper level typing/computer skills
• Fluent in a foreign language, preferably Spanish and willing to obtain certification as a translator

Experience

• Minimum one-year and 2 shifts per week availability to work

Knowledge, Skills & Abilities

• Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
• Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA
• Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
• Ability to multi-task and consistently communicate in a professional manner
• Treat all information, data and training materials utilized in the scope of the Scribe position with complete confidentiality and security.
• Cooperates fully with all risk management activities and investigations.
• Observes and complies with Hospital Codes of Safe Practice, safety policies and emergency procedures.