Scribe

About the Role

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.
• Use the team approach to patient care and documentation.
• Ensure 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.
• Respond to improvement opportunities in a positive manner.
• Communicate in a professional and respectful manner to the supervising physician and 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.
• Cooperate fully with all risk management activities and investigations.
• Adhere to policies and procedures regarding medical terminology and approved abbreviations.

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.

Sonora Behavioral Health is committed to providing equal employment opportunities to all applicants regardless of protected characteristics under applicable laws.