Medical Scribe

Hot Springs Health Clinics Medical Scribe

DEPARTMENT: Hot Springs Health Clinics SUPERVISOR: Director of Nursing-Clinics EMPLOYEE NAME: APPROVED BY: Director Clinic Operations DATE: June 2025 GENERAL: In accordance with the Hot Springs Health Personnel Policy and Procedure Manual and the requirements of our accrediting bodies, the employee will: support the mission “ Partnering with our community for quality health and healing”, the five core values “ O wnership, A lways Better Than Yesterday, S ervice First, I ntegrity, and S tewardship of Our Resources (OASIS)”.

Our behavior creates our OASIS – a place where we can find safety, sustenance, and a pleasant change from the usual and vision of “ being the provider and employer of choice in our region, providing the highest quality care and excelling as a teaching hospital in Wyoming .” The established priorities of Quality, Service, Finance, People, and Growth, will be utilized in decision making. Furthermore, the employee will demonstrate the ability to manage time, maintain a safe and clean environment; practice confidentiality; treat all persons with respect and professional courtesy; accept change; accept and provide constructive feedback; work as a team player and adhere to the infection control, fire and safety, disaster and hazardous waste policies.

The employee must also demonstrate the competencies for their position and adhere to policies and procedures of their department. The employee will participate in quality improvement activities. BEHAVIORAL

The following is a list of minimally required behaviors to assist the employee in partnering with our community: Ownership Accepts responsibility for actions, attitudes and health. Doing things right the first time, every time for excellent results. Accepts ownership of mistakes and takes constructive action to avoid repeating mistakes.

Works with empowerment to the highest potential both as an individual and as part of the team. Unsatisfied with the status quo or just being “good.” Always Better Than Yesterday Performs at the highest level, always learning and looking for ways to improve, with an unwavering focus on safety. Celebrates and encourages the contributions of one another.

Constructively challenges the status quo by being flexible, adaptable and embracing change as a key element of our future success. Contributes to an environment that encourages creative thinking. Shares ideas and opinions, and supports opportunities to learn and grow.

Service First Doing our best every day to anticipate and exceed the expectations of patients, providers and co-workers. Understands excellence is the result of team effort. Creates legendary experiences.

Integrity Does the right things. Consistently open, honest, trustworthy and ethical. Demonstrates respect for patients, their families, staff, providers and the community.

Stewardship of Our Resources Strives to care wisely for our human, financial and natural resources. Strengthens HSH as a partner in the community. POSITION STATUS: This position is a Non-Exempt position.

Generally expected to work 5 days a week.

AND

1. Assists with increasing the efficiency and the productivity of the physician to allow them to focus on the patient 2. Anticipates physician’s needs to facilitate the flow of the clinic 3.

Must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care 4. Shows good judgement, organizational ability, initiative, and attention to detail 5. Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician 6.

Documents patient medical history, physical exam, procedures, treatments performed by the physician, licensed nurses and medical assistants. 7. Documents patient education and explanations of risks and benefits 8. Documents diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up 9.

Prepares, sends and makes follow up calls for patient referrals 10. Prepares and sends correspondence as directed by the physician 11. Proofreads medical note to spot mistakes or inconsistencies in medical documentation and correct the information 12.

Ensures all clinical data, lab or other test results and the interpretation of the results by physician are recorded accurately in the medical record. Alerts physician when chart is incomplete. 13. Proofreads and edits the physician’s medical documents for accuracy, spelling, punctuation, and grammar 14.

Collaborates well with both patients and medical professionals and assists with tracking patient follow-up and compliance. 15. Reviews daily schedule with care team every morning prior to patients being seen. 16. Prepares chart for non-acute appointment 1-2 days prior to patient appointment.

During chart prep determine if the patient is up to date with labs, imaging (bone density scan, mammogram, etc.), procedures (colonoscopy, pap, etc.), and immunizations. 17. Accurately proposes all orders the provider wishes to order during appointment for patient. 18. Assists provider in making sure all medications are refilled with enough refills to last until next patient appointment. 19.

Ensures referrals are sent for next appointment or patient is given appointment card prior to leaving exam room. The above duties are intended to describe the key aspects of the work performed by individual(s) assigned to this position. They are not to be construed as an exhaustive listing of requirements relative to the position.

Therefore, the employee may be required to perform other duties as assigned. QUALIFICATION

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the

. EDUCATION and/or EXPERIENCE The Medical Scribe Staff shall be: 1. Medical Scribe Certification preferred 2. 1-3 years’ experience working with EMR/medical records preferred. 3.

Experience working with Cerner highly desirable 4. Experience working with electronic medical records 5. Good understanding of medical terminology 6.

Intermediate typing and data entry skills LANGUAGE

Ability to read appropriate journals. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write policies and procedures that conform to prescribed style and format.

Ability to effectively present information to top management, public groups, and/or boards of directors. MATHEMATICAL

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent. REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to modify care based on the developmental / functional age of the patient as well as that of the patient's ethnic background. CERTIFICATES, LICENSES, REGISTRATIONS: BLS OTHER SKILLS AND ABILITIES: Ability to act as a patient advocate.

Ability to interact with patients, families, visitors and co-workers. Ability to interact assertively and tactfully when dealing with conflict and in group solving activities. Ability to demonstrate a professional, open minded approach in identifying problems and resolving problems/conflicts.

Age Specific: This position does not require hands-on delivery of care; however, incumbent must demonstrate understanding of how a patient’s chronological and developmental age influences his/her need for adaptations related to his/her abilities. PHYSICAL DEMANDS: 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

. While filling this position, the employee must regularly lift and or move 10 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this position include close vision, distance, vision, color vision, peripheral vision, and depth perception.

This position also requires walking or standing to a significant degree. This position also requires reaching, handling, fingering, feeling, talking, and hearing, stooping, bending, crouching, and working with equipment. WORK ENVIRONMENT: The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the

. The employee is subject to inside and possibly outside weather conditions. The employee is also subject to exposure to blood and body fluids, proximity to moving mechanical parts, electrical shock, exposure to toxic chemicals and biological agents.

Days shift · Monday-Friday