Job description

Position Summary:
The primary responsibilities of the Medical Scribe are to document all relevant dictated or written information for the treatment of patients into the electronic health record. Medical Scribes will be responsible for clearly recording each patient's symptoms, history, physical exam, documenting the diagnoses, and treatment plans as dictated by the clinician while abiding by all local, state, and federal guidelines for documentation into electronic medical records. The Medical Scribe is not a direct patient care role.

Essential Functions of the Job:

• The Medical Scribe accompanies the clinician into the patient examination area in order to transcribe a patient history and physical examination.
• Under the direction of the clinician, transcribes patient orders, including laboratory tests, radiology tests, referrals, etc.
• Documents any procedures performed by the clinician or nurses.
• Transcribes any consultations and/or discussions with family.
• Lists all proper diagnoses as well as any follow up instructions as dictated by the clinician.
• Assists the clinician in reviewing and transcribing prior internal and external medical records.
• At the end of the patient encounter or shift, provides the scribed documentation for the clinician to review to ensure all events were recorded accurately.
• Make recommendations for continued process improvement to the Scribe Manager.

Prohibited Scope of Service:

• Patient Care: The scribe is not directly involved with patient care; however, he/she may be asked to give patient paperwork during visit or discuss discharge instructions with a patient. The scribes’ direct interaction with patients is limited.
• General Documentation: A scribe cannot document any of his/her personal objective findings or be involved in any of the medical decision-making. A scribe cannot act independently; instead, he/she must simply document the physician's dictation and or/activities during the visit.Additional Duties and Responsibilities:
• Maintains confidentiality of all patient and employee information and adheres to all HIPAA requirements.
• Informs supervisor of matters of general interest and problem areas determined or discovered.
• Attends all SYHealth mandatory meetings and other meetings as requested.
• Demonstrates openness to organizational and/or departmental changes.
• Personally commits to advancing a customer request or correcting customer service problems and does so undefensively.
• Remains engaged in their work.
• Understands and adheres to all SYHealth policies and procedures.
• Adheres to and consistently demonstrates SYHealth’s Core Values of Respect, Excellence, Empowerment and Integrity.

Job Requirements
Education Required (Minimum level of education):
- High School diploma or equivalent is required.
- A strong academic history required.
- Successful completion of any relevant additional college-level courses is preferred, i.e. medical terminology, anatomy, physiology, etc.

***Compensation will be analyzed after Hiring Manager interview have been completed. Specific pay rate will be calculated on two factors: Years of relevant experience in role, and internal equity.Please note the maximum end of pay range is reserved for candidates with 15+ years of experience.

Job Types: Full-time, Part-time

Pay: $16.59 - $25.00 per hour

Schedule:

• Monday to Friday

Work Location: In person

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