Medical Scribe

About Us:

Sonoma Specialty Hospital, as the county’s only Long-Term Acute Care Hospital, is dedicated to caring for patients that require an extended acute care stay due to severe illness or catastrophic injury. We accept patients from the ICU, Step-Down and Telemetry units of partner hospitals and continue their care for as long as 45 days. This care focuses on the challenges of getting patients off of ventilator support, healing severe wounds, aiding their recovery following surgical procedures, and providing rehabilitation to speed their return to daily life. Our Hospital provides ICU, Surgical, and Step-Down care with dialysis, multi-specialty therapies and ongoing planning for the patient’s transition back home or into a lower level of care. Please contact us with any questions, and welcome to Sonoma Specialty Hospital.

Job Summary:

The Medical Scribe will work closely with physicians in a fast-paced Long-Term Acute Care Hospital (LTACH) setting, providing documentation support for a 58-patient census. The scribe will assist in real-time charting, ensuring accurate and efficient electronic health record (EHR) documentation to enhance physician productivity and patient care.

Education, Licensure and/or Certifications: 

• High school diploma required;


• Pre-med, nursing, or healthcare-related degree preferred
  

Duties and Responsibilities:

•    Accompany physicians during rounds, documenting history & physicals (H&Ps), progress notes, consult notes, discharge summaries, and orders in the EHR.
•    Record physician-patient interactions, exam findings, assessments, and treatment plans accurately.
•    Update patient charts with lab results, imaging reports, and consultant recommendations.
•    Ensure timely completion of medical documentation to meet compliance and billing requirements. 
•    Assist in reconciling medication lists, problem lists, and past medical history. 
•    Format notes according to hospital policy (e.g., SOAP, APSO, or narrative style). Prepare pre-rounding reports by reviewing patient charts for updates.
•    Flag critical lab/imaging results for physician review.
•    Coordinate with nursing and ancillary staff to streamline communication.
•    Adhere to HIPAA and hospital confidentiality policies.
•    Maintain accurate records for audits and quality metrics.

Experience and Qualifications: 

• Basic computer skills required. 


• Prior medical scribe experience (1+ year preferred), especially in hospital, LTACH, or critical care setting.


• Strong attention to detail, multitasking ability, and professionalism in high-stress environments.


• Familiarity with medical terminology, common LTACH diagnoses (e.g., ventilator weaning, wound care, sepsis), and clinical workflows.
  

It is the policy of Sonoma Specialty Hospital not to discriminate against any applicant for employment, or any employee because of age, color, sex, disability, national origin, race, religion, or veteran status.