Health Information Management Scribe

Job Summary

The scribe is responsible to capture accurate and detailed documentation of patient encounters in the electronic health record (EHR) or by handwritten record. Scribes are not permitted to make independent decisions or translations while entering information into the medical record.

Responsibilities

• Assist the physician in navigating the EHR.
• Respond to various messages as directed by the physician.
• Locate information for review (i.e., previous notes, reports, test results, lab results).
• Entering information into the medical record as directed by the physician (click or type).
• Researching information as requested by the physician.
• Recording handwritten information using approved downtime procedures when necessary.
• Assist the physician in ensuring all critical documentation is available and recording for accurate coding.
• Set up Normals and templates for clinicians.
• Assist new clinicians in efficient use of Dragon and Cerner.
• Act as liaison with Desktop Support to troubleshoot any issues.
• Order tests, blood work, etc. or other services for patient as direction by physician. (Follow up as physician directs during patient visit).
• Other duties as assigned.
• Support nursing with their daily clerical duties.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company’s attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education 

• High School Diploma or GED (Required) Experience: 2 yrs experience in medical office, clinical, or hospital setting. Medical transcription experience is preferred. Substitutions: Formalized training in Medical Transcription, Medical Terminology, and/or Physiology may be substituted for 2 yrs experience

Credentials 

• No Certification, Competency or License Required

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Cancer Center Building

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org

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