As a condition of employment, all Roanoke Chowan Community Health Center new hires are required to be COVID-19 vaccinated prior to your first day of employment. Accommodations to begin the vaccination process can be scheduled with RCCHC’s Occupational Health on your first day should you choose to do so. In accordance with the American with Disabilities Act (ADA), reasonable accommodations can be made for employees with disabilities that prevent them from receiving the vaccine. Similarly, Title VII of the Civil Rights Act of 1964 requires employers to provide reasonable accommodations for individuals who notify us of sincerely held religious beliefs that prevent them from receiving the vaccine.

JOB DESCRIPTION

POSITION TITLE: Medical Scribe

REPORTS TO: Nurse Manager

SUPERVISORY RESPONSIBILITY: None

DEPARTMENT: Clinical Operations

POSITION STATUS: Non-Exempt

SALARY RANGE:

POSITION SUMMARY: Under the direct supervision and presence of the Practitioner (Physician and/or Mid-level Provider), the Medical Scribe provides annotation, under their own profile, in the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations/guidelines for documentation. The Medical Scribe will be responsible for clearly recording each patient’s symptoms, history, physical exam and documenting the diagnosis. The Medical Scribe is not a direct patient care provider.

The Patient Account Representative will model behaviors consistent with the published values and the Code of Conduct of RCCHC.

POPULATION SERVED: Roanoke Chowan Community Health Center will provide open access, community-oriented primary care of the highest quality to all residents within our service area and surrounding counties, regardless of their ability to pay.

QUALIFICATIONS:

• Bachelor’s degree preferred. Equivalent combination of education and/or work experience with a minimum of 2 years in healthcare.
• Medical terminology and Pharmacology knowledge preferred.
• Basic computer skills with excellent verbal and written communication skills.
• Demonstrated knowledge and ability competencies in writing and Spanish interpretation preferred.

ESSENTIAL FUNCTIONS:

• Accompany the physician and/or mid-level provider into the patient examination area in order to transcribe findings in real time as the provider evaluates the patient.
• Documents the history of the patient’s chief complaint as given by the patient and communicated by provider.
• Documents the review of systems (ROS) and physical examination as given by patient and communicated by provider.
• Transcribes under the direction of provider, patient orders, including laboratory tests, imaging tests, etc.
• Completes the procedure note on behalf of the provider as directed.
• Looks up pertinent past medical records at the direction of the provider.
• Keeps track of and enters the results of imaging studies as directed by the provider.
• Enters documentation on patient progress as directed by provider.
• Lists proper diagnosis as well as any discharge/follow-up instructions and prescriptions, as dictated by the provider.
• Reviews the record and verifies that the documentation requirements have been met for the designated code assigned by the provider.
• Follows documentation compliance standards.
• Assures that the Electronic Health Record is complete and that all pertinent documentation requirements are met, including the diagnosis, disposition and patient education interventions.
• Ensures the provider reviews the Electronic Health Record for accuracy. Obtains provider signature, under the provider’s profile, for each encounter.
• Develop and maintain a mutually respectful working relationship with all providers.
• Available for provider concerns, questions, and is ready to assist in documentation at all times.
• The Medical Scribe does not participate in patient care. All requests to participate in any patient care to the provider or nursing staff.
• Relays messages to the nursing staff, medical assistants, and/or patient to expedite patient flow throughout the department.
• Maintain compliance with workflows, policies, and procedures as well as other activities to support PCMH model of care and accreditation.
• Adhere to all state and federal privacy regulations, including HIPAA, OSHA, and other regulatory agencies and RCCHC policies and procedures regarding confidentiality, privacy, and security requirements for OCHIN EHR access.
• Support compliance with all privacy and security requirements pursuant to community partners’ and outside provider’s patient confidentiality agreements, including privacy and security requirements for OCHIN EHR access.
• Knowledge of OCHIN EHR and related systems functionality.
• Knowledge of PCMH and other FQHC data reporting requirements.
• Maintain confidentiality, sensitivity, understanding, and respect for diverse populations inclusive of patients of varying social, economic, cultural, ideological and ethnic backgrounds.
• Ability to communicate clearly and concisely both orally and in writing, including technical writing, interpersonal skills, and speaking to groups of employees.

Other job duties may be required that are not listed above.