Medical Scribe

at CHC-SEK in Bartlesville, Oklahoma, United States

Job Description

Description

This position will be part-time in Pittsburg and part-time in Parsons. 

GENERAL DESCRIPTION

The scribe position is part of the clinical team. This position is responsible for accurately and thoroughly gathering and transcribing medical information into the electronic medical record (EMR) during a patient's encounters with a provider. This position should have a comprehensive knowledge of the EMR in order to provide consistent documentation and identify errors in medical documentation. The scribe should anticipate the provider's needs in order to facilitate the flow of patients through the clinic.   

Requirements

ESSENTIAL DUTIES

1. Act as an extension of the provider performing documentation.
2. Accurately and thoroughly document medical visits and procedures as they are being performed by the provider and at the direction of the provider, including but not limited to:
3. medical history and physical exam,
4. clinical data, lab, x-ray, or other test results,
5. procedures and treatment including orders as specified by the provider, 
6. provider interpretations of results,
7. medication and prescription updates and orders,
8. patient education, patient/family follow-up and self-care, 
9. Enter lab information/results.
10. On occasion may sort and scan medical documentation into the electronic medical record.
11. Collect the data for Meaningful Use, UDS reporting, PCMH, clinic performance improvement activities, and other program accreditations. 
12. Collaborate with clinic support staff to assure the patient's electronic record is complete.
13. Comply with specific standards that apply to the legal and ethical requirements for preparing medical documents and protecting patient's health information.