JOB SUMMARY:

The primary purpose of the Medical Scribe is to assist the provider during the patient visits by manually entering appropriate information as dictated by the provider into the Electronic Health Record (EHR). The Medical Scribe will be responsible to capture all accurate and detailed documentation of the patients visit in a timely manner. The provider will review and approve every task of the Medical Scribe and will take full responsibility with their signature, for the information recorded electronically in the patients chart.

The Medical Scribe will also work as a Medical Assistant as part of our Care Team. The Care Team Medical Assistant is an active member of the care team and is primarily responsible for assisting patients throughout the routine office visit and helping their assigned patient panel with health management. The Care Team Medical Assistant works with the medical staff as part of a multidisciplinary team to provide comprehensive, quality and accessible health care services to the communities of Sonoma County Indian Health Project, Inc. (SCIHP). SCIHP is dedicated to wellness, compassion, affordability, and excellence of care.

ESSENTIAL FUNCTIONS:

Medical Scribe

• Accompany providers into the patient examination room in order to transcribe the history into the EHR as directed by the provider. Accurately documents the providers encounter with the patient and others present.
• Recording providers consultations with other healthcare professionals, patients and family members.
• Ensures all clinical data, laboratory or other test results as well as the interpretation of these results by the provider is recorded accurately into the Electronic Health Record (EHR).
• Enters all proper diagnoses, and symptoms as well as follow-up instructions and prescriptions as dictated by the provider into the Electronic Health Record (EHR).
• May work indirectly by transcribing electronic notes.
• Documents all procedures performed by the provider.
• Performs other duties as assigned

• Fosters an environment that promotes trust and cooperation among all staff at SCIHP.
• Enforces clinic policies and procedures to ensure that the principles of SCIHP are implemented.
• Maintains strict confidentiality of all patient information.
• Informs supervisor and or medical director of general interest, concerns and problem areas as discovered or determined.
• Understands and adheres to Compliance and Code of Conduct Policy.
• Understanding of billing codes to help increase efficiency.
• Patient Privacy Act and HIPAA trained.

Certified Medical Assistant

• Actively engage in the teamwork of SCIHP and our mission.
• Actively participate as an integral and valued member of the patient Care Team.
• Prepare for the patient visit in advance including ensuring that all labs, diagnostics, etc. are ready and available for the visit. Checks CHDP charts to make sure patient is due for WCC.
• Must comply with all federal, state and local laws and regulations, and SCIHP policies.
• Welcome patients as they arrive at the health center and immediately assist them back to the exam room.
• Perform administrative responsibilities as needed, including verification and entry of patient insurance coverage and existing demographic information into the electronic health record.
• Assist with clinical data measure and entry into the electronic health record including the patients height, weight, and vital signs including pulse rate, temperature, blood pressure, respiratory rate, BMI, etc.
• Gain expertise in preventative and chronic disease guidelines and assists patients in understanding the health benefits of screening and prevention. Assist in discharging the patient at the completion of the office visit including going over the printed office visit summary; aid in the completion of medication, laboratory, and radiology orders; provide patient education information ordered by the provider; answer any final logistical questions the patient may have; and assist in follow-up appointment scheduling.
• Prepare exam rooms before and after each patient in accordance with SCIHP policy and OSHA guidelines, including restocking of exam rooms, literatures and operatories.
• Assist medical providers with exams and procedures as requested (i.e. colposcopies, biopsies, vasectomies, pelvic, circumcisions, casting, etc.).
• Perform in-house lab tests (HCT, rapid strep, urine dips/spins, Hgb A1C, serum glucose, urine pregnancy, etc.) as directed by the provider and/or RN. See that correct billing information is sent out with specimens for off-site lab tests and maintains log of all specimens.
• Instruct patients re: specimen collection for urinalysis; completes urinalysis via dipstick according to policy Ensures lab specimens (those sent to the outside lab) are properly processed including paperwork.
• Perform vision and hearing tests, EKGs, ABTs, ear irrigation, immunizations, dressing applications and other activities as requested.
• Run population data queries to determine which patients would benefit from recommended health screening, GPRA indicators, preventative services and established chronic disease tracking interventions. Participates as a valued member of the care team to assist patients in meeting these recommended health guidelines.
• Clean, sterilize and maintain equipment and instruments as needed.
• Is aware of and complies with all OSHA regulations (i.e., universal precautions, handling of sharps, personal protective equipment/clothing, etc.)
• Maintain patient confidentiality in accordance with SCIHP policy and HIPAA guidelines.
• Ensures expedient return of health records to Health Information Department (HIM) per protocol.
• May administer medications (oral, sublingual, topical, inhalation, via nebulizer) or provide a single dose to a patient for self-administration; prior to administration, the licensed medical provider, Podiatrist, RN or Pharmacist must verify the drug, dosage, allergy status.
• May administer immunizations per provider order; must be cognizant of immunization schedule as recommended by ACIP (pink book) and California Department of Public Health (CDPH). Ensures correct needle length, site, route are adhered to; verifies/double checks orders with the provider. Anticipates the needs of the providers whenever possible.
• Carries out health maintenance procedures as allowed by standardized procedures.
• Assists providers with paperwork and collection of records needed to ensure quality patient visits.
• Cleans exam rooms after each patient and at the end of the day.
• Checks expiration dates for supplies and medications as outlined in Nursing/MAs Responsibilities and disposes of expired items via pharmacy, lab or Nursing Director.
• May act as the late Medical Assistant to complete clinic day.
• Adheres to Blood borne Pathogen Control Plan and disposes of sharps per protocol.
• Actively participate in quality improvement projects and reporting.
• If qualified, will be requested to assist with medical translation and interpreting.
• Will be expected to perform other duties as assigned (i.e., checking of crash cart, QA procedures, phone back-up, inventory, ordering of supplies, etc.)

EDUCATION AND EXPERIENCE:

• High school graduate or equivalent.
• Completion of an accredited Medical Assistant training program certificate.
• CCMA (California Certified Medical Assistant) Certificate.
• Minimum of a two year degree, or two years or more experience in a health care setting preferred or at least one year experience as a Medical Scribe.
• Medical Scribe Certification preferred but not required.
• Knowledge of Medical Terminology.
• Experience with Electronic Health Record
• Knowledge of ICD-10 Coding
• CPR-Cardiopulmonary Resuscitation Certification

QUALIFICATIONS

• Experience in an outpatient setting or working in a health clinic desired.
• Able to operate the following equipment; microscope, centrifuge, glucometer, nebulizer, EKG, cholestech, HgA1c and clinitek machines.
• Must be knowledgeable and familiar with medical terminology.
• Must be able to listen to complex medical information and summarize in a clear, complete, and concise manner.
• Must be computer literate and possess excellent spelling, editing and grammar skills.
• Must demonstrate professionalism.
• Must have excellent organizational skills and the ability to multi task.
• Ability to type 45-60 WPM.
• Must have excellent Customer Service skills positive attitude, and be a team player.

SPECIAL QUALIFICATIONS:

Must be sensitive to the needs of the Native American Indian community, their culture, traditions, behavioral patterns, and background.

COMPETENCIES:

• Analytical Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.

• Problem Solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Project Management- Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.
• Customer Service- Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
• Judgment- Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
• Planning /Organizing- Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.
• Professionalism- Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit. Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Cost Consciousness - Works within approved budget; Contributes to surpluses and revenue; Develops and implements cost saving measures; Conserves organizational resources.
• Diversity - Shows respect and sensitivity for cultural differences promotes a harassment-free environment; Builds a diverse workforce.
• Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
• Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; supports organization's goals and values; Benefits organization through outside activities; Supports affirmative action and respects diversity.
• Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.
• Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; Reports potentially unsafe conditions; Uses equipment and materials properly.
• Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
• Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan.

PHYSICAL REQUIREMENTS:

While performing the duties of this job, the employee is regularly required to have manual dexterity; reach with hands and arms, stoop, or kneel; and talk and hear within normal, range., The employee is frequently required to stand, walk, sit, climb, or balance. The employee must regularly be able to lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. This position is physically and emotionally challenging. There is a high degree of stress. Ability to deal with time constraints and emotional stress and exposure to body fluids and viruses are also essential, functions of this job.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Frequent possible exposure to blood borne/airborne pathogens or infectious materials.
• Noise level ranges from quiet to moderate.