Scribe, Cardiology Clinic

The duties of a Scribe are to perform any and all clerical and information technology functions for a clinician including documenting the clinician dictated patient history, physical examination, family, social, past medical history, procedures, lab results, radiographic impressions and any other information pertaining to the patient’s encounter in any clinical medical setting. Primary goal is to increase the efficiency and productivity of the clinician while enhancing the patient experience. This position will report to the Clinical Coordinator

Job Requirements

Minimum Education

• High School Diploma or equivalent is required.
• Two to four years of undergraduate education preferred.
• Certified Medical Scribe preferred.

Minimum Work Experience

• Prior related work experience preferred but not required.
• Prior experience can count in lieu of years of education.

Required Skills

• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
• Ability to spell, proofread and edit written text.
• Keyboard proficient. 
• Ability to operate a personal computer and related software applications.
• Strong attention to detail.
• Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.
• Ability to coordinate multiple projects and patients.
• Ability to problem solve under pressure.
• Ability to communicate and interact professionally with others.
• Commitment to high professional ethical standards.

Functional Demands

Physical Requirements

Sitting - 16-31%

Walking - =>32%

Standing - =>32%

Bending/Squatting - 16-31%

Climbing/Kneeling - 16-31%

Twisting - 16-31%

Osha Category

High Potential for Direct Body Fluid Exposures

Visual and Hearing Requirements

Must be able to see with corrective eyewear.

Must be able to hear clearly with assistance.

Other Physical/Environmental Demands

Lifting - 0-50lbs, 50lbs or more with assistance

Carrying - 0-50lbs, 50lbs or more with assistance

Pulling - up to 100lbs

Pushing - up to 100lbs

Leadership Capabilities

Mission, Service, and Values

Supports the hospital Mission, Service and Values.

Essential Functions

Accurately and thoroughly document medical visits and procedures as they are being performed by the clinician, including but not limited to:

•  Patient medical history and physical exam,
•  Procedures and treatments performed by the healthcare professionals, including nurses and physician assistants,
•  Patient education and explanations of risks and benefits,
•  Physician dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow up.
•  Diagnostic findings, lab and test results, consultations with other providers, treatment course, discharge instructions and prescriptions.

1. Prepare referral letters as directed by the physician, via dictation or summary of the medical record. Ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
2. Spot inconsistencies or mistakes in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.
3. Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
4. Collect, organize and catalog data for Physician Quality Reporting System and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.
5. When the physician concludes the patient’s encounter, the clinician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The clinician is ultimately responsible for documentation of the patient’s encounter.
6. The clinician and the scribe will make “chart rounds” to review patient status, delays, and any other care related issues.
7. All orders for patient care must be communicated by the physician and not the scribe.
8. Professional, non-intrusive interaction with patients (the scribe does not directly assist with patient care), physicians, hospital staff and other co-workers.
9. Compliance with hospital policies, including those relating to confidentiality of patient information.
10. Excellent job attendance.
11. Other duties as assigned, including but not limited to training other Scribes and staff.

Nonessential Functions

• Core Competencies
•  Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.
•  Strong written and verbal communication skills.
•  Ability to actively listen.
•  Demonstrates the knowledge and skills necessary to document patient care as dictated by a clinician in a legible and clear manner, following all local, state and federal guidelines for documentation.
•  Ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
•  Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
•  Ability to spell, proofread and edit written text.
•  Keyboard proficiency (no less than 70 words/minute).
•  Ability to operate a personal computer and related software applications.
•  Strong attention to detail.
•  Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal medical issues.
•  Ability to coordinate multiple projects and patients.
•  Ability to problem solve under pressure.
•  Ability to communicate and interact professionally with others.
•  Commitment to high professional ethical standards.

Organizational Expectations

T.J. Pledge

I Will Show Compassion

• see all patients, family members, coworkers, physicians, and anyone else at T.J. as my customer.
• recognize that each and every interaction I have at T.J. Regional Health matters
• show kindness and compassion towards my customers at all times
• be sensitive to the personal and private needs of every customer

I Will Cooperate With Others

• maintain zero tolerance for abusive behavior
• listen and be willing to accept fault when I make a mistake
• never underestimate the power of an apology
• refrain from blame and judgment
• bring a sense of calm to stressful situations

I Will Collaborate With Others

• value myself and every coworker as an equal part of one GREAT team working together
• treat others in a way that I would like to be treated
• participate only in conversations that are courteous, respectful, and reflect positively on my teammates and T.J. Regional Health
• foster a calm and pleasant atmosphere, and refrain from gossip, rumors, and insults
• speak honestly, seek truth, and act with integrity towards my teammates
• value the uniqueness and expertise that each team member contributes to the whole
• meet the need of the moment, regardless of whether or not it is considered part of my job

I Will Communicate

• smile - at everyone
• always introduce myself, my role, and my purpose use body language, eye contact, and tone of voice that shows respect in every interaction
• follow the 10/5 rule: always acknowledging people at 10 feet away with a smile and always greeting people at 5 feet away
• escort any customer in need (visitors, patients) to their destination

I Will Adapt To Change

• be a part of the solution when I am presented with a challenge
• embrace change and set the example for those around me
• accept openly when there are changes that T.J. Regional and/or I have no control over
• manage the expectations of others by explaining duration and next steps as often as needed

I Will Be A Champion

-Serve With Passion

• view myself as an owner of T.J. Regional Health and act accordingly
• take responsibility for the physical appearance of T.J. Regional Health, including my work area
• go out of my way to daily thank and compliment my customers and coworkers
• dare to make a difference and be exceptional
• constantly try to improve myself and T.J. Regional Health
• speak positively about T.J. Regional, while at work and in public places outside of work