Medical Scribe

Description

Position Summary

The duties of a Scribe are to document the dictated patient history, physical examination, family, social, and past medical 

histories as well as document procedures, lab results, dictated radiographic impressions and any other information 

pertaining to the patient’s encounter at NeighborHealth Center. 

Principal Duties and Responsibilities*

1. The Scribe is assigned to work with a provider and accompanies the provider upon patient interview and 

examination.

2. The Scribe documents:

   a. the dictated patient history, including history of present illness, review of systems, past medical and 

    surgical histories, family and social histories, medications, and allergies. 

   b. physical examination findings and procedures as performed by the provider. 

   c. the results of laboratory and radiographic studies as dictated by the provider. 

   d. the correct time of patient care related activities, including provider to provider communication, family 

    communication and re-examinations of the patient. 

3. The provider and the Scribe will review patient status, delays, and any other care-related issues. 

4. The Scribe will order lab test, diagnostic studies, and prescriptions as dictated by the provider for cosignature by 

the provider.

5. The Scribe will 

   a. Maintain and demonstrate an understanding of the team approach to patient care and documentation. 

   b. Complete and present the medical record in collaboration with the supervising provider. 

   c. Communicate in a professional and respectful manner to the patient, supervising provider, and ancillary 

    clinical staff.

Requirements

Required Skills or Abilities*

1. Excellent computer literacy in internet use and Windows environment, including Outlook, Word, and Excel with superior keyboarding skills.
2. Demonstrate the knowledge and skills necessary to document patient care as dictated by a provider in a clear manner, following all local, state, and federal guidelines for documentation.  
3. Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations. 
4. Demonstrate organizational ability to maintain and coordinate both electronic and paper records related to patient care for multiple patients at a time.
5. Ability to multi-task and consistently communicate in a professional manner.
6. Advanced knowledge of medical terminology, anatomy, physiology, and pharmaceuticals.
7. Ability to handwrite and type large amounts of dictated information.
8. Ability to cultivate and develop inclusive and equitable working relationships with co-workers and community members.
9. Ability to serve as an advocate for individuals of all ethnicities, genders, ages, and backgrounds.

Required Knowledge, Experience, or Licensure/Registration

1. High School education or equivalent
2. Ability to work onsite Mondays through Thursdays during the hours of 7:45am and 5:15pm.
3. Ability to read, write, speak, and comprehend English fluently.
4. Vaccines as required.

Physical requirements of the Job*

1. Sitting or standing (often for prolonged periods) 
2. Normal or corrected vision and hearing.

This is a full-time, nonexempt position.

*To comply with the Americans with Disabilities Act of 1990 (ADA), which prohibits discrimination against qualified individuals on the basis of disability, it is necessary to specify the physical, mental and environmental conditions of the essential duties of the job.

NeighborHealth Center is an Equal Opportunity Employer, including disability and veterans. NHC is dedicated to building a culturally diverse staff committed to serving a diverse patient population.