Scribe

Harboroaks; Tucson (AZ); On-site; USD 30,000 - 42,000; Full time

Job summary

Sonora Behavioral Health in Tucson seeks a detail-oriented Medical Scribe to support physicians during patient evaluations, accurately documenting histories, examinations and orders in real time.

Candidate must maintain HIPAA privacy, handle confidential information securely, and work as part of a collaborative team to ensure precise medical records and quality patient care.

Qualifications

• High school diploma or equivalent required.
• One or more years’ administrative/scribe experience required.
• Knowledge of administrative and clerical procedures and systems such as managing files and records.

Responsibilities

• Accompany the physician during examination of the patient.
• Accurately document the physician dictated patient history, history of present illness, pertinent findings, mental status examination, medications and allergies.
• Accurately document the results of laboratory and radiographic studies as dictated by the physician.Accurately document the diagnoses, procedures, risk factors, and plans as dictated by the physician.
• Uses the team approach to patient care and documentation.
• Ensures all orders for patient care are communicated by the physician and not the Scribe.
• Complete and present the medical record in collaboration with the physician.
• Maintain confidentiality and privacy in accordance with governing HIPAA regulations.
• Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner.
• Cooperates fully with all risk management activities and investigations.

Skills

Administrative experience

Scribe experience

HIPAA compliance

Education

High school diploma or equivalent

Job description

Overview

Sonora is a leading behavioral health provider, operating a 140-bed inpatient hospital along with ECT and outpatient therapy services. Located in Tucson, Arizona, we are dedicated to serving children, adolescents, and adults across all stages of behavioral health needs. Our team is committed to delivering high-quality, compassionate care, and we are seeking motivated, dedicated professionals to join us in making a meaningful impact in the communities we serve.

PURPOSE STATEMENT:

Provide administrative support to facility Physician to ensure efficient dictation of patient notes and situations.

Responsibilities

• Accompany the physician during examination of the patient.
• Accurately document the physician dictated patient history, history of present illness, pertinent findings, mental status examination, medications and allergies.
• Accurately document the results of laboratory and radiographic studies as dictated by the physician.Accurately document the diagnoses, procedures, risk factors, and plans as dictated by the physician.
• Uses the team approach to patient care and documentation.
• Ensures all orders for patient care are communicated by the physician and not the Scribe.
• Complete and present the medical record in collaboration with the physician.
• Responsive to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician, ancillary hospital staff.
• Demonstrate the knowledge and skills necessary to document patient care as dictated by a physician in a legible and clear manner, following all local, state, and federal guidelines for documentation.
• Maintain confidentiality and privacy in accordance with governing HIPAA regulations.
• Treat all information, data and training materials utilized in the scope of the Scribe position with complete confidentiality and security.
• Cooperates fully with all risk management activities and investigations.
• Adheres to policies and procedures regarding medical terminology and approved abbreviations.

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• High school diploma or equivalent required.

• One or more years’ administrative/scribe experience required.

• Knowledge of administrative and clerical procedures and systems such as managing files and records.

SONBH

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