Tri-City Medical Center Medical Scribe-OSNC in Oceanside, California

Position Summary:

The medical scribe works to facilitate patient flow and ensure an accurate and complete medical record for each patient. The Medical Scribe assists the medical provider by accompanying them during the medical history-taking and exam, recording details of both into the medical record.

Duties and Responsibilities

Administrative

  • Maintains a clean and organized work area

  • Maintains working knowledge of orthopedic medical terminology and accepted abbreviations

  • Understands and recognizes the physical exam process and has the ability to record exam details

  • Is computer proficient and able to quickly learn new applications

  • Tracks patient care and improves patient flow

  • Demonstrates a professional demeanor and recognizes privacy considerations for patients and families

  • Displays flexibility in scheduling

  • Calmly copes with a high pressure environment

Clinical

  • Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies

  • Records details of physician exam, including pertinent positives and negatives, noted abnormalities and patient general condition

  • Submits orders as desired by medical provider and checks constantly for results of those orders

Performs other duties as assigned

Safety and Infection Control Responsibilities

Responsible to maintain a safe and clean working environment, including unit based specific safety and infection control requirements

Essential Organizational Behaviors

  • Demonstrates behaviors that are consistent with the Medical Center’s Mission and Values

  • Performs job responsibilities in an ethical, compliant manner consistent with the Medical Center’s values, policies, procedures and code of conduct

  • Works well with team members toward a common purpose. Reinforces the efforts and goals of the work group. Supports the team’s decision, regardless of individual viewpoint.

  • Demonstrates flexibility in schedules and assignments in order to meet the needs of the Work Unit/Department

  • Utilizes, maintains, and allocates equipment and supplies in a cost-effective manner. Improves productivity through proper time management

  • Seeks feedback from customers and team members in order to identify and improve processes and outcomes.

Physical demands

  • The physical demands described below are representative of those that must be met by an employee to successfully perform the role of a Medical Scribe. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to sit, stand, and ambulate as needed

  • Able to use hands and fingers to handle objects, tools, and controls

  • Has ability to reach with arms

  • Must be able to talk and hear

  • Must have adequate vision

  • Assist with patient transfers (bending , lifting, etc)

Competencies

  • High school diploma or equivalent

  • Six months of Medical Scribe experience or related clinical training, required

  • Strong medical terminology

  • Ability to work under stress with interruptions and deadlines

  • Ability to process verbal information and proceed accordingly

  • Ability to follow complex instructions

  • Ability to use basic math skills needed to write prescriptions and draw injections

  • Ability to think logically and critically and come to a conclusion

  • Computer proficiency with Windows applications

  • Ability to type a minimum of 45 WPM

  • Ability to use the phone system, copier, fax and printers

  • Ability to navigate the EHR system

  • Ability to communicate with a high level of medical knowledge to patients, staff, management, Physicians and others

  • Knowledge of CPT, ICD-9/ICD-10, and HCPCS coding

  • Demonstrated awareness of the patient as an individual, with specific physical, psychological and spiritual needs

  • Obeys and adheres to all policies and procedures outlined in the handbook

  • Strong writing skills and spelling proficiency

Preferred Education and Experience

  • Certified Medical Assistant

  • Experience with Electronic Medical Records

Other Duties

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential duties of this job in a fully competent manner. This should not be considered as a detailed description of all work requirements for the position. The characteristics of the position and the standards of performance may be changed by TCMC with or without prior notice, based on the needs of the organization

Req No: 2018-7132

Shift: Day

Cost Center/Dept: 7095 - OSNC

Work Schedule: M-F 8 hours

External Company Name: Tri City Healthcare District

External Company URL: http://www.tricitymed.org/