It is the responsibility of the medical scribe to document information gathered during clinic visits in real time under the direction of the clinician in adherence with local, state, and federal guidelines for documentation in the electronic health record.
Essential Functions
Documentation
The primary role of the medical scribe is to assist the clinician with documentation in chart notes during patient encounters (in clinic, telemedicine, or virtual). Documentation includes but is not limited to medical history, subjective and objective information, review of systems, physical exam, assessments, treatment plans, and procedures notes. Transcription of diagnostics results may also be included in documentation if requested by the clinician.
Assistance with Ordering of Diagnostics/Referrals
In addition, the medical scribe will, based on the instructions of the clinician, prepare orders such as labs, diagnostic imaging, in office procedures, point of care tests, preventative health screenings, and referrals for the clinician to sign.
Coordination of Care Assistance
Scribes act as an additional line of communication between the providers and other ancillary team members or clinic resources (case management, integrated behavioral health, AOD, nutrition, referral coordinators, call center/patient service representatives, MA/nursing, etc.), either verbally or electronically, in order to ensure patient receives comprehensive services in a timely manner.
Clerical Duties
Scribes may be assigned clerical task assigned by their supervisor that include but are not limited to manual data mining from the EHR, chart audits, assisting with development of and participating in medically related quality improvement projects, distribution of workflow training material, and document management.
Additional Duties
Active participation in team huddles
Active participation in quality improvement initiatives
Active participation in multidisciplinary committees and workgroups
Assist with the training of new staff in collaboration with leadership and preceptors/mentors
Active collaboration with clinical and non-clinical staff to ensure care is proactive, coordinated, and timely
Other duties as assigned
Education/Experience Required
Diploma or GED equivalent
Some College
Diploma or GED equivalent
Some College
Minimum typing speed of 40 WPM
Strong English writing skills including grammar, format structuring, and spelling
Ability to identify issues, think critically, and problem solve independently
Ability to work effectively in a team setting
Exposure to a medical related field, typically gained with at least 6 months of:
Previous employment as a medical scribe
Employment in a clinic, hospital, or other medical setting
Volunteer experience in a clinic, hospital, or other medical setting
Volunteer experience in community programs focused on health outcomes
Clinical research experience
Relevant coursework (including but not limited to medical terminology, anatomy, physiology, biology, microbiology, pharmacology)
Preferred
Experience navigating an electronic health record
Proficiency in Microsoft programs (Word, Excel, PowerPoint)
MSCAT certification or completion of an accredited scribe certification program
Medical assistant certification
Ability to dedicate themselves to the role for at least one year.
Reasonable Accommodations
One Community Health endorses and supports the Americans with Disabilities Act of 1990 (ADA) and the California Fair Employment and Housing Act (FEHA) and is committed to providing reasonable accommodations to qualified individuals with disabilities who are applicants or employees who need accommodations. If you require and accommodation due to a disability to complete this application or you are experiencing difficulty submitting your application, please contact us at [email protected]
Our Benefits
For more information on the comprehensive benefits we provide, please visit: https://onecommunityhealth.com/careers/benefits/
Salary: $23.62 - $29.88 per hour
Job Posted by ApplicantPro
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at One Community Health Sacramento by 2x