Major Responsibilities:

• Medical documentation
  • 1)Scribe will be logged into the system with their own unique login information. Documentation will include name of scribe and provider rendering services.
  • 8)Document after clear direction from provider during patient visit. Once provider has completed visit the scribe will review with the patient any orders and instructions given by the provider for check out.
  • 2)Scribe will enter health information into the EMR for documentation. Only yes or no questions will be asked by the scribe to the patient. Scribe will note dictation of provider to include HPI, Quality, current Medications, Allergies, history, and assessment/plan. Scribe will not engage in medical decision management making nor will the scribe do any medical interpretation of information received from the patient. The scribe only repeats and documents what patient has said and /or described.
  • 3)Scribe may review and update the patient history,including Family History, Surgical History, Smoking, Alcohol, and Substance Abuse History. They may also update allergies and the Medication list. Updates include new allergies, verification of pateint pharmacy benefits, correct pharmacy, verification of current medications, and refill orders being requested by the patient. The provider is responsible for entering new medications, orders that are not standing orders, and Review of Systems. The provider is also responsible for the Medication Reconciliation and final verification of all informaiton obtained by the scribe. The provider must sign the attestation verifying the information the scribe entered is correct.
  • 4)Respond to various messages as directed by the provider.
  • 5)Locate information for review (i.e., previous notes, reports,imaging, test results, and lab results). Scribe will work with the team to have the POC testing as ordered by the provider completed. Provider will review results and enter order; unless it is a standing order that the staff may enter.
  • 6)Research any information requested by provider.
  • 7)Adherence to standing order policies and procedures.
  • 9)Scribe will complete all aspects of the chart in preparation for the provider to complete their portion.
  • 10)All notes must be reviewed and authenticated by the provider. Clinical summary will be printed and provided to the patient at the completion of the visit. If the patient has further questions, they can discuss with the provider. Upon request of provider, the scribe or medical assistant will print or obtain and give to the patient any requested educational information. The scribe will escort the patient to the check out station. Attestation clause will be signed by the scribe.
• Patient Satisfaction and Service: Provides efficient,high quality service to patients while assisting the provider and with follow up after the provider has completed the visit.
  • 1)Consistently demonstrates sincere understanding and empathy in interactions with the patients.
  • 2)Consistently adheres to Medical Hills Internists service standards and MVP.
  • 3)In collaboration with team, meets or exceeds established patient satisfaction targets.
  • 4)Treats patients, families and associates with respect and incorporates cultural differences into interactions/care.
  • 5)Participates in activities to evaluate and improve processes that will contribute to patient, associate, and provider satisfaction.
  • 6)Responsible for conveying a professional image in compliance with Medical Hills Internists' clothing and grooming standards, and wears Medical Hills Internists' provided identification tag at all times.
  • 7)Completes all required customer service training and complies with scripting initiatives.
  • 8)Creates and maintains an environment that is patient centered.
  • 9)Promotes achieving visit volume targets.
  • 10)Attentive and responsive to the needs and concern of the patients, associates, and physicians and works closely to resolve issues with involved parties.
• Health Information Managment(HIM) and HIPAA standards: A complete and accurate electronic medical record will be maintained for every individual who is evaluated or treated withing the medical group.
  • 1)Maintains confidentiality in all aspects of patient care and communication in person and via the telephone.
  • 2)Makes certain that the medical record and all relevant diagnostic reports are available at the start of the visit.
  • 3)Medical release of information following HIPAA policy and when involving another identified party.
  • 4)Disposes and shreds papers containing patient identifiable information according to policy.
  • 5)Maintains medical record loose filing by directing to appropriate personnel.
  • 6)Adheres to form standardization protocol.
• Funding Our Future:
  • 1)Understands order completion and documentation for appropriate charge capture and risk reduction.
  • 2)Works with provider and billing department to accurate code and capture charges.
  • 3)Maintains inventory par levels using standard products, and paying attention to waste.
  • 4)Understands revenue and expense management targets and is engaged in achieving same.
  • 5)Promotes a green environment by adhering to organizational guidelines for recycling and prudent utilizaiton of resources.
  • 6)Utilizes organizational resources in a resonsible/cost effective manner.
  • 7)Has considerable terminology understanding.
• Miscellaneous
  • 1)Keeps abreast of current standards of care and documentation.
  • 2)Participates in in-services and other professional and growth opportunities.
  • 3)Completes annual competency reviews.
  • 4)Mainatins any certifications or memberships in professional organizations if they exist.
  • 5)Other duties as assigned.
• Risk/Safety Compliance
  • 1)Complies with established OSHA safety standards and Accrediting Organization regulations.
  • 2)Maintains work area in accordance with the facility site checklist.
  • 3)Complies with infection control standards.
  • 4)Participates in annual safety training and demonstrates Culture of Safety behaviors/techniques.
  • 5)Maintains department orderliness and cleanliness.
  • 6)Reports all non-compliance and incident occurrences and completes appropriate reporting method.
  • 7)Quality liaison who actively participates in medical record audits.

Education/Experience Required:

• Medical terminology course preferred but not required or 1 year experience in medical office.

Knowledge, Skills & Abilities Required:

• Good communication skills. Proficient with keyboard and computers.
• CPR

Physicial Requirements and Working Conditions:

• Ability to travel locally to multiple sites if needed. Ability to work in stressful conditions and difficult situations. Resilient and flexible in a changing environment. May be exposed to hazardous materials and life threatening diseases. Ability to cooperate and work with others. Ability to make sound and timely decisions. Ability to work rotating shifts any day of the week. Ability to perform lifting, transfer activities related to patients as needed, ability to stoop/bend.
• Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist. Unique patient lifting/movement situations will be assessed at the time and team with another associate, when available.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.