JOB SUMMARY:

Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the provider. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients. The Medical Scribes will follow all local, state and federal guidelines regarding documentation into the electronic health record. The Medical Scribe will be responsible for clearly recording each patients symptoms, history, physical exam and documenting the diagnosis. This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front desk staff.

ESSENTIAL FUNCTIONS:

• The primary role of the Medical Scribe is to assist the provider with documentation of patients medical chart during his or her visit.
• Accompanies the provider into the patient examination room in order to transcribe the patient history and physical examination as given by the patient and provider.
• Documents any procedures performed by the provider or nurses, on the electronic medical chart.
• Is an expert in the use of various templates and documentation techniques available in the EHR (Electronic Health Record) system, and use these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
• Transcribes any consultations or discussions with family members and/or the provider.
• Completes the patients chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the medical scribe continuously checks on the progress of this data in order to get the patients workup complete so the provider is able to make decisions regarding the patient.
• Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
• Performs other duties as assigned.

EDUCATION AND EXPERIENCE:

• High school graduate or equivalent.
• Medical Scribe Certification and Aptitude Test (MSCAT) certification after 200 hours on the clinic floor, preferred.

QUALIFICATIONS

• Previous experience working in an outpatient clinic or doctors office.
• Medical Terminology, Anatomy and Physiology Coursework.
• Ability to type 45-60 WPM.
• Must have excellent Customer Service skills, positive attitude, and be a team player.
• Maintain confidentiality of all patients, and employee information.

SPECIAL QUALIFICATIONS:

Must be sensitive to the needs of the Native American Indian community, their culture, traditions, and background.

COMPETENCIES:

• Analytical Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.

• Problem Solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Project Management- Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.
• Customer Service- Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Judgment- Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Planning /Organizing- Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.
• Professionalism- Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit. Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
• Diversity - Shows respect and sensitivity for cultural differences promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
• Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Benefits organization through outside activities; Supports affirmative action and respects diversity.
• Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
• Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; Reports potentially unsafe conditions; Uses equipment and materials properly.
• Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
• Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan.

PHYSICAL REQUIREMENTS:

While performing the duties of this job, the employee is regularly required to have manual dexterity; reach with hands and arms, stoop, or kneel; and talk and hear within normal, range. The employee is frequently required to stand, walk, sit, climb, or balance. The employee must regularly be able to lift and/or move up to 25 pounds.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Frequent possible exposure to bloodborne/airborne pathogens or infectious materials.
• Noise level ranges from quiet to moderate.