Scribe - Lead

Harboroaks; Tucson (AZ); On-site; USD 36,000 - 48,000; Full time

Job summary

Harboroaks is seeking a Medical Scribe to support a physician by documenting patient encounters, histories, medications, and exam findings in a legible, compliant manner.

The role emphasizes HIPAA privacy, accurate charting, and collaboration with hospital staff to ensure timely, high-quality medical records and efficient patient care processes within a hospital setting.

Qualifications

• Requires a high school diploma or equivalent.
• One or more years of administrative or scribe experience.
• Knowledge of administrative procedures and record-keeping systems.

Responsibilities

• Accompany physician during patient examination.
• Accurately document patient history, findings, medications, and allergies as dictated by physician.
• Document lab and radiology results and diagnoses per physician guidance.
• Collaborate with the medical team to ensure complete and legible records.
• Ensure orders for patient care are communicated by the physician, not the scribe.
• Prepare and present medical records in coordination with the physician.
• Maintain confidentiality and comply with HIPAA and local regulations.
• Communicate professionally with supervising physician and hospital staff.

Skills

Administrative skills

Scribe experience

HIPAA knowledge

Education

High school diploma

Job description

Overview

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

• 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.

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