Medical Scribe 7125# 13282

Oroville Hospital•Oroville, CA

3d•$26 - $35

About The Position

Under the direct supervision and presence of the Practitioner (Physician and/or Mid-level Provider), the Medical Scribe provides annotation, under their own profile, in the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations/guidelines for documentation. The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. The Medical Scribe is not a direct patient care provider.

Requirements

High school graduate or equivalent
American Heart Association (AHA) Basic Life Support (BLS) Provider certification or American Red Cross Basic Life Support for Healthcare Providers certification
Knowledge of medical terminology, anatomy and physiology required
Must be able to type on a keyboard at least 40 wpm, with ability to increase speed while maintaining accuracy required
Demonstrated experience working with medical providers and allied health professionals
Demonstrated ability to work well under pressure in a critical environment and maintain attention to detail in order to accurately document encounter
Demonstrated observation, listening, interpersonal, and clarification skills in order to interact positively and productively with provider and patient
Demonstrated knowledge of computers and technology
Demonstrated ability to multi-task and organize
Demonstrated excellent verbal and written communication skills
Demonstrated strong desire to learn
Ability to maintain confidentiality

Nice To Haves

Completion of sophomore year of college in pre-med, nursing, EMT/Paramedic, Chemistry/Biology or other professional or allied health field preferred
Intent to to Advanced Studies in the Medical Field is preferred

Responsibilities

Accompany the physician and/or mid-level provider into the patient examination area in order to transcribe findings at the bedside in real time as the provider evaluates the patient
Documents the history of the patient's chief complaint as given by the patient and communicated by provider
Documents the review of systems (ROS) and physical examination as given by patient and communicated by provider
Transcribes under the direction of provider, patient orders, including laboratory tests, imaging tests, etc.
Completes the procedure note on behalf of the provider as directed
Looks up pertinent past medical records at the direction of the provider
Keeps track of and enters the results of imaging studies as directed by the provider
Enters documentation on patient progress as directed by provider
Lists proper diagnosis as well as any discharge/follow-up instructions and prescriptions, as dictated by the provider
Reviews the record and verifies that the documentation requirements have been met for the designated code assigned by the provider
Follows documentation compliance standards
Assures that the Electronic Health Record is complete and that all pertinent documentation requirements are met, including the diagnosis, disposition and patient education interventions
Ensures the provider reviews the Electronic Health Record for accuracy. Obtains provider signature, under the provider's profile, for each encounter
Develop and maintain a mutually respectful working relationship with all providers
Available for provider concerns and questions and is ready to assist in documentation at all times
The Medical Scribe does not participate in any patient care and should refer all requests to participate in any patient care to the provider or nursing staff. Relays messages to the nursing staff, medical assistants, and/or patient to expedite patient flow throughout the department
Performs other duties as assigned