Scribe (outpatient) Job at Adventist Health
Adventist Health Lodi Memorial, one of the region’s premier nonprofit healthcare providers, comprises a 190-bed hospital, 17 medical practice locations and wellness programs. Since we opened our doors in 1952, we have been committed to those who seek our care. Through the decades, Lodi Memorial became not just a hospital, but a pillar for the surrounding community and the people whose pasts and families are intertwined with the organization.
Job Summary:
Assists physicians in hospital and clinic setting to efficiently compile complete and detailed electronic medical records/patient charts. Documents medical visits and procedures as they are being performed by physician including, but not limited to, patient medical history and physical exam, procedures/treatments performed by healthcare professionals, including nurses and physician assistants, patient education and explanations of risks and benefits, physician-dictated diagnoses, and prescriptions and instructions for patient or family members for self care/follow-up.
Job Requirements:
Education and Work Experience:
- High School Education/GED or equivalent: Preferred
- Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred
Essential Functions:
- Prepares referral letters as directed by the physician, via dictation or summary, of the medical record. Ensures letters are mailed or faxed on a daily basis to all physicians involved in patient’s care, and with all copies of pertinent reports or tests attached.
- Researches contact information for referring physicians, coordinates referrals, prepares operative reports, makes phone calls and performs other clerical tasks as assigned.
- Spots mistakes or inconsistencies in medical documentation and checks to correct information. Ensures all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record. Alerts physician when chart is incomplete.
- Complies with specific standards and legal/ethical requirements for preparing medical documents and for keeping patient information confidential.
- Collects, organizes and catalogs data for Physician Quality Reporting System and other quality improvement efforts. Formats for submission. Assists in developing and maintaining systems to track patient follow-up and compliance.
- Performs other job-related duties as assigned.
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