Scribe - Lead

Acadia Healthcare; Tucson (AZ); On-site; USD 34,000 - 44,000; Full time

Job summary

Acadia Healthcare is seeking a Medical Scribe to support an on-site physician in Tucson, AZ. You will document patient histories, notes, labs, and imaging results as dictated by the physician, ensuring accuracy and legibility.

You will accompany the physician during examinations, maintain HIPAA confidentiality, and collaborate with the care team to improve documentation quality.

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.

Skills

Administrative experience

Scribe experience

Education

High school diploma or equivalent

Job description

Purpose Statement

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

• 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.

Purpose Statement

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

• 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.

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.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual's characteristics protected by applicable state, federal and local laws.