Clinical Scribe - Lincoln Hills

CarDon & Associates•New Albany, IN

About The Position

The Clinical Scribe plays a critical role in supporting healthcare providers by accurately documenting resident encounters in real-time, ensuring comprehensive and precise medical records. This position facilitates efficient resident care by allowing clinicians to focus on direct resident interaction while the scribe manages detailed charting and data entry. The Clinical Scribe must have a strong understanding of medical terminology, resident care processes, and clinical workflows to capture relevant information effectively. Working closely with physicians and nursing staff, the scribe helps maintain compliance with healthcare regulations and supports quality assurance initiatives. Ultimately, this role contributes to improved resident outcomes and streamlined clinical operations.

Requirements

High school diploma or equivalent required.
Basic computer literacy, including proficiency with electronic health record (EHR) systems and standard office software.
Strong understanding of resident care fundamentals, including vital signs measurement and infection control protocols.
Excellent listening and communication skills to accurately capture clinical information in real-time.
Ability to maintain resident confidentiality and adhere to HIPAA regulations.

Nice To Haves

2 years of experience as a Clinical Scribe, Assistant, Transcriptionist, or Medication Aide.
Completion of a medical scribe training program or relevant healthcare coursework.
Familiarity with wound care procedures and documentation.
Knowledge of medical terminology and clinical workflows.
Experience working in a fast-paced clinical environment.

Responsibilities

Accompany healthcare providers during resident visits to document history, physical exams, procedures, and treatment plans accurately and promptly.
Record vital signs, wound care details, and infection control measures as observed or reported during patient encounters.
Ensure all documentation complies with legal, regulatory, and institutional standards for medical records.
Collaborate with clinical staff to clarify information and ensure completeness and accuracy of resident charts.
Utilize electronic health record (EHR) systems to enter and update patient information efficiently.
Performs basic clerical work, including faxing, fielding phone calls, and ensuring all email correspondence is addressed.