Medical Scribe

Community Health at Home; College Station (TX); On-site; USD 10,000 - 60,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Scribe to support practitioners in documenting patient visits effectively. This role involves capturing detailed information in electronic health records, assisting with data retrieval, and ensuring accuracy in documentation. The ideal candidate will have a high school diploma and be enrolled in college courses, with a preference for those holding a Bachelor's degree. Join a compassionate team committed to building healthy communities and making a difference in patient care. If you are detail-oriented and passionate about healthcare, this opportunity is perfect for you.

Qualifications

• High school graduate with enrollment in college courses is required.
• 1 year of experience in a similar position is required.

Responsibilities

• Document visit elements in a patient's electronic health record during practitioner visits.
• Assist the practitioner in navigating the medical record and capturing accurate documentation.

Skills

Knowledge of Medical Terminology

Education

High School Graduate

Bachelor's Degree

Job description

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Responsibilities

Documents defined visit elements in a patient's electronic health record on behalf of a practitioner while being physically present in the room with the practitioner.

1. Documents or records the visit elements exactly as stated by the practitioner without interjecting his or her own observations or impressions.
2. Captures accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner.
3. Assists the practitioner in navigating the medical record.
4. Responds to various messages as directed by the practitioner.
5. Locates information for review (e.g., previous notes, reports, test results, and lab results).
6. Documents information into the medical record as directed by the practitioner.
7. Enters information in the electronic health record such as patient history, system review and physical examination, vital signs, procedures and treatments performed by the practitioner, care plan and medication lists, progress of lab, x-ray or other patient evaluation data, and practitioner dictated diagnoses, prescriptions and instructions.
8. Researches information requested by the practitioner.
9. Must make entries in the electronic health record using their own password/access for all entries and must clearly include the name of the scribe and a legible signature/electronic signature, the name of the practitioner rendering services, qualifications of each person, and authentication of the scribe, including accurate date and time of service.
10. Supports practitioner in care documentation and data retrieval.
11. Performs other duties as assigned to meet the organization’s needs.

Qualifications

Education

Required: High School graduate, enrolled in college courses
Preferred: Bachelor's Degree

Experience

Required: 1 year of experience in a similar position
Preferred: 2 years experience in a similar position or clinic setting

Skills

Preferred: Knowledge of Medical Terminology