CMA - Scribe
Southeast Health
Southeast. Always the right career direction.
Job Description Summary
Utilizing the skill and knowledge of a Certified Medical Assistant renders direct and indirect patient care in support of medical care in accordance with established standards of care, as well as policies and procedures of Southeast Health while also performing duties of a Scribe. Responsible for promoting positive relationships and teamwork among employees and between departments.
Job Description
Essential Functions
+ Performs clinical care activities for individuals in the clinics
+ Actively accepts, understands, and practices appropriate standards of scope of practice.
+ Contributes to triage, rooming, and direct care once ordered for patients.
+ Participates in the implementation of patient care.
+ Actively supports the mission, vision, and values of the clinics
+ Performs various activities related to the needs of adult and geriatric clinic patients in accordance with established policies and procedures.
+ Scribes accompany the provider upon patient interview and examination.
+ Scribes document the provider dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.
+ Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety
Scribe Responsibilities:
The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter in the Emergency Department or other clinical medical setting. Scribes are not patient care providers; they are the physician’s representative
+ Scribes document physical examination findings and procedures as performed by the provider.
+ Scribes document the results of laboratory and radiographic studies as dictated by the provider.
+ Scribes document the correct time of patient care related activities, including provider-to-provider communication, family communication and re-examination of the patient.
+ When the provider concludes the patient's encounter, the provider will review all documentation completed by the scribe, make any necessary amendments and sign the chart. The provider is ultimately responsible for documentation of the patient's encounter.
+ The provider and the scribe will make "chart rounds" to review patient status, delays and any other care-related issues on an as needed basis.
+ The provider and not the scribe must communicate all orders for patient care unless the scope of the scribe allows for verbal order communication
+ Complete and present the medical record in collaboration with the supervising physician.
Supervised Positions
+ None
Qualifications
Minimum Education Required
+ High school graduate or equivalent
+ Approved medical scribe application through Medical Staff Services prior to start date
+ Certified Medical Assistant (CMA) – a graduate of a Medical Assistant program that awards certification and/or credentials by examination and program; clinical hours completed
+ Must successfully complete Southeast Health pharmacology exam
Minimum Education Preferred
+ BCLS certification
Minimum Experience Required
+ Medical office experience
Minimum Experience Preferred
+ Medical office experience
+ Computer literacy in Windows based programs
Required Skills/Abilities
+ Maintain current, Medical Assistant certification
+ Maintain current, BCLS certification, if attained
+ Excellent typing skills
+ Strong listening skills
+ Computer literacy in Windows based programs preferred
+ Effective telephone techniques
+ Excellent attention to detail
+ Ability to focus in a moderately active environment
+ Ability to operate business machines to include fax and copier
+ Manual dexterity
+ Ability to effectively communicate in English both in writing and orally
+ Ability to effectively communicate in an emergency situation
+ Ability to perform patient assessment including, but not limited to: vital signs, history, medication reconciliation and administering meds.
+ Ability to document in an electronic medical record.
+ Demonstrates commitment to organizations five (5) priorities and Six Ground Rules
+ Person in this position is required to understand, agree upon and follow our Six Ground Rules:
+ No excuses.
+ We are a team.
+ Bring up your ideas.
+ Poor performance will be addressed.
+ ‘That’s not my job’ is not acceptable
+ Manage Up.
Shift
DayShift Details
First
FTE
1
Type
Regular
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Equal Employment Employer
Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.
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