Medical Scribe & Documentation Specialist

DHR Health; Edinburg (TX); On-site; USD 42,000 - 60,000; Full time

Job summary

DHR Health is seeking a Documentation Specialist to assist physicians with complete documentation of patient charts in the Urology Clinic. The role involves accompanying physicians during exams and hospital rounds, recording observations in EMR, and ensuring accurate charting and follow-up information.

Qualified candidates will have a high school diploma or GED, medical terminology knowledge, and office software skills; CNA/MA certification preferred.

Qualifications

• High School graduate or equivalency preferred.
• Medical Terminology required.
• CNA or Medical Assistant certification from an accredited school preferred.
• Computer skills required with knowledge of Microsoft Office suite.
• Good written and verbal communication skills required.

Responsibilities

• Promotes the facility mission, vision and values by effectively communicating them to others.
• Keep track of laboratory tests, medications, and radiology tests ordered by the physician.
• Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records).
• Coordinate communication between physicians and staff, make and answer telephone calls.
• Document any consultations the physician makes to a patient’s personal doctor, family members, on-call physician, or other members of the medical community.
• Take vital signs and room patients as needed.
• Accompany provider to hospital to document consults or hospital rounds as needed.
• Provide patients with updates about waits and delays.
• Document all procedures done by the physician, as dictated by the physician.
• Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient.
• Other duties as assigned.
• Requires reasoning ability and good independent judgment.

Skills

Medical Terminology

Communication skills

Customer service

Attention to detail

Education

High School diploma or GED

Medical terminology certification (preferred)

CNA or Medical Assistant certification (preferred)

Tools

Microsoft Office

EMR systems

Job description

DHR Health is seeking a Documentation Specialist to assist physicians with complete documentation of patient charts in the Urology Clinic. The role involves accompanying physicians during exams and hospital rounds, recording observations in EMR, and ensuring accurate charting and follow-up information.

Qualified candidates will have a high school diploma or GED, medical terminology knowledge, and office software skills; CNA/MA certification preferred.