The Lead Medical Scribe supports back office, team members and main role as a scribe to multiple Medical Providers, including Pediatric and Adult Medicine. It will be the responsibility of the medical scribe to annotate any dictated or written information for the treatment of patient following all local, state, and federal guidelines for documentation into the electronic health record (EHR). The medical scribe will be responsible for clearly recording each patient's symptoms, history, physical exam, and documenting the diagnosis as well as treatment plans. The medical scribe is not a direct patient care role. Only Licensed Independent Providers (MD, DO, OD) are allowed to use scribes.

Lead- Specific Tasks and Duties:

• Lead Scribe has the ability to delegate as necessary to Medical Scribes. Lead Scribe has authority to invoke disciplinary action including verbal warnings in conjunction with the Clinic Manager and/or Regional Clinic Director. 
• Lead Scribe plans and delivers training and in-services with input/support from Clinic leadership including but not limited to Medical Director, MA Supervisors, Lead RN, Front Office Supervisor, Clinic Manager and Regional Clinic Director.
• Lead Scribe will work with the Clinic Manager regarding employment (hiring/terminating) of Medical Scribes.
• Lead Scribe is responsible for assisting Clinic Manager with Medical Scribes performance evaluations.
• Other duties as assigned.

Scribe-Specific Tasks and Duties:

• At the start of the visits all scribes must check the “document scribed” checkbox on the intake template at the top center.
• The primary role of the Medical Scribe is to assist the Provider with documentation of each patient's medical chart during his/her visit.
• The scribe accompanies the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and provider.
• The scribe, under the direction of the provider, transcribes patient orders, including laboratory tests, radiology tests, referrals etc. When transcribing orders start with “Per. [PROVIDER NAME, TITLE] order.”
• The scribe documents any procedures performed by the provider or nurses, in the EHR.
• The scribe transcribes any consultation or discussions with family and/or the provider.
• The scribe completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient's workup complete so that the provider is able to make his/her decisions regarding that patient.
• The scribe lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
• The scribe does not directly assist with patient care. The scribe documents orders generated by the provider.
• The scribe assists the clinician and support staff with paperwork, telephone calls, faxing, and chart abstraction.
• The scribe is able to process portal communications and either task to appropriate staff or get information from the provider to respond to the patient in a timely way.

Scribes are prohibited from the Following Tasks:

• Medications: A scribe cannot prescribe medications. Scribes cannot stop, start, or make any manipulation to any medications in the "medication module”.
• Orders: A scribe cannot order any in-house medications that are injected, ingested, or inhaled into the body including nebulizer treatments. The expectation being immunizations.
• Document Sign Off: The provider should always review the record and attest to its correctness and completeness. At the end of the day or shift, the provider should review the scribed documentation to ensure all events were recorded accurately. The provider generates the document, creating the completed "Master IM." The scribe does not.
• Patient Care: The scribe is not directly involved with patient care; however, he/she may be asked to give patient paperwork during visit or discuss discharge instructions with a patient. They interact with patients on a limited level. For exceptions to this section, please see the “Optional Trainable Skills” section below.
• General Documentation: A scribe cannot document any of his/her personal objective findings or be involved in any of the medical decision-making. A scribe cannot act independently; instead, he/she must simply document the provider’s dictation and or/activities during the visit.

Optional Trainable Skills:

With the permission of medical/operational leadership and participation in an in-house training/competency program, a Scribe can be trained to perform vitals, room patients.

Education and Experience:

• High School Diploma or Equivalent (GED) required.
• Experience with EPIC Electronic Health Records preferred.
• BLS Certification required.

Required Skills and Abilities:

• Must be able to communicate effectively in English (able to read, write and speak).
• Bilingual in Spanish a required.
• Ability to multi-task work duties.
• Ability to work as a team.
• Excellent interpersonal skills.
• High attention to detail.
• Excellent follow-up ability.
• Ability to use a computer and work with electronic health records.

Education and Experience:

• High School Diploma or Equivalent (GED) required.
• Experience with EPIC Electronic Health Records preferred.
• BLS Certification required.

Benefits:

Our mission informs our approach to your benefits program. Our benefits program is designed to protect your health, family and way of life. We offer a competitive Benefits Program that includes affordable health insurance and Health Reimbursement Accounts (HRA), Dental and Vision Insurance, Educational and Continuing Education Benefits, Student Loan Repayment and Loan Forgiveness, Retirement Plan, Group Life and AD&D Insurance, Short term and Long Term Disability benefits, Professional Fee Reimbursement, Mileage and Cell Phone Reimbursement, Scrubs Reimbursement, Loupes Reimbursement, Employee Assistance Programs, Paid Holidays, Personal Days of Celebration, Paid time off, and Extended Illness Benefits.