Medical Scribe

CHI; College Station (TX); On-site; USD 35,000 - 50,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated medical scribe to support practitioners in documenting patient encounters. This role involves accurately recording visit elements in electronic health records, ensuring timely and precise documentation while assisting healthcare professionals. The ideal candidate will possess a high school diploma and have a foundational knowledge of medical terminology. Join a mission-driven organization that is committed to building healthy communities and innovating healthcare delivery across the nation.

Qualifications

• 1 year of experience in a similar position required.
• Preferred: 2 years of experience in a clinic setting.

Responsibilities

• Documents visit elements in a patient's electronic health record.
• Captures accurate documentation of the encounter in a timely manner.
• Assists the practitioner in navigating the medical record.

Skills

Knowledge of Medical Terminology

Education

High School diploma

Bachelor's Degree

Job description

Responsibilities

1. 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.
2. Records the visit elements exactly as stated by the practitioner without interjecting personal observations or impressions.
3. Captures accurate and detailed documentation of the encounter in a timely manner, using handwritten, electronic, or other methods.
4. Assists the practitioner in navigating the medical record.
5. Responds to various messages as directed by the practitioner.
6. Locates information for review, such as previous notes, reports, test results, and lab results.
7. Documents information into the medical record as directed by the practitioner.
8. Enters information into the electronic health record, including patient history, system review, physical examination, vital signs, procedures, treatments, care plans, medication lists, lab and imaging results, and practitioner diagnoses and instructions.
9. Researches information requested by the practitioner.
10. Makes entries in the electronic health record using personal password/access, clearly including the scribe's name, a legible signature/electronic signature, the practitioner's name, qualifications, date, and time of service.
11. Supports the practitioner in care documentation and data retrieval.
12. Performs other duties as assigned to meet organizational needs.

Qualifications

Education

• Required: High School diploma; enrolled in college courses.
• Preferred: Bachelor's Degree.

Experience

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

Skills

• Preferred: Knowledge of Medical Terminology.

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., including clinics, hospitals, home-based care, and virtual services, CommonSpirit is accessible to nearly one in four U.S. residents. Our mission is to build healthy communities, advocate for the poor and vulnerable, and innovate healthcare delivery both inside hospitals and in the community.