Website Borrego Health
Summary: The Clinical Scribe duties include performing all clerical and information technology functions for a provider in a clinic setting including documenting the details of the patient/provider encounter in any clinical medical setting. This includes primary responsibility of the operation of the electronic health records system. Primary goal is to increase the efficiency of the provider while enhancing the patient experience and access to care.
Essential Duties and Responsibilities:
- Accurately and thoroughly document medical visits and procedures as they are being performed by the provider in real time, including but not limited to:
- Patient medical history and physical exam
- Procedures and treatments performed by the healthcare professionals
- Patient education and explanations of risks and benefits
- Provider dictated diagnoses, and instructions for patient or family members for self-care and follow up
- Diagnostic findings, lab and test results, consultations with other providers, treatment course, and discharge instructions
- Prepare referral letters as directed by the provider, via dictation or summary of the medical record. Ensure that letters are mailed or faxed daily to all providers involved in a patient’s care, and with all copies of pertinent reports or tests attached. Research contact information for referring providers, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
- Spot inconsistencies or mistakes in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a provider. Ensure that all clinical data, lab, or other test results, the interpretation of the results by the provider are recorded accurately in the medical record. Alert providers when chart is incomplete.
- Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents while keeping patient information confidential.
- Collect, organize and catalog data for Provider Quality Reporting System and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow-up and compliance.
- When the provider concludes the patient’s encounter, the provider will review all documentation completed by the Scribe, make any necessary adjustments, and sign the chart. The provider is ultimately responsible for accuracy and completion of the encounter documentation.
- The provider 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 provider and not the scribe.
- Professional, non-intrusive interaction with patients (the scribe does not directly assist with patient care), providers, clinical staff and other co-workers.
- Compliance with clinic policies, including those relating to confidentiality of patient information.
- Excellent job attendance.
- Other duties as assigned
- Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job
- Strong written and verbal communication skills
- Ability to actively listen
- Demonstrates the knowledge and skills necessary to document patient care as dictated by provider in a legible and clear manner, following all local, state, and federal guidelines for documentation
- Ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations
- Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English
- Ability to spell, proofread and edit written text
- Keyboard proficiency and accuracy (60WPM)
- Ability to operate a personal computer and related software applications
- Strong attention to detail
- Ability to focus in a dynamic, fast-paced environment
- Ability to coordinate workflows
- Ability to problem solve under pressure
- Ability to communicate and interact professionally with others
- Commitment to high professional ethical standards
- Graduate of approved High School or GED Equivalent
- Healthcare education certificates and/or work experience, preferred.
- Strong medical terminology skills, preferred.
- All staff that is presently working within a clinic is required to have a Current and Valid CPR and First Aide certification.