Patient Care Recorder

2 weeks ago

Raleigh, North Carolina, United States Neighbor Health Center Full time
Job Overview

Position Summary

The role of a Scribe involves accurately recording the dictated patient history, physical assessments, family and social backgrounds, as well as previous medical histories. Additionally, the Scribe documents procedures, laboratory results, radiographic impressions, and any other relevant information concerning the patient's visit at Neighbor Health Center.

Key Responsibilities*

  1. Collaborate with a healthcare provider, accompanying them during patient interviews and examinations.
  2. Document the following:
  • Dictated patient history, including current health issues, system reviews, past medical and surgical histories, family and social backgrounds, medications, and allergies.
  • Findings from physical examinations and procedures performed by the provider.
  • Results from laboratory and imaging studies as dictated by the provider.
  • Accurate timing of patient care activities, including communications between providers, family interactions, and patient re-evaluations.

3. Engage in discussions with the provider regarding patient status, delays, and other care-related matters.

4. Assist in ordering laboratory tests, diagnostic studies, and prescriptions as directed by the provider for co-signature.

5. Uphold and demonstrate a comprehensive understanding of teamwork in patient care and documentation.

  • Complete and present medical records in partnership with the supervising provider.
  • Maintain professional and respectful communication with patients, supervising providers, and ancillary clinical staff.

Essential Skills and Abilities*

  1. Proficient in computer usage, particularly in internet applications and Windows environment, including Outlook, Word, and Excel, with excellent typing skills.
  2. Ability to document patient care as directed by a provider clearly, adhering to all applicable guidelines for documentation.
  3. Commitment to maintaining confidentiality and privacy in accordance with HIPAA regulations.
  4. Organizational skills to manage both electronic and paper records for multiple patients simultaneously.
  5. Capacity to multitask while consistently communicating in a professional manner.
  6. Advanced understanding of medical terminology, anatomy, physiology, and pharmaceuticals.
  7. Proficient in handwriting and typing extensive amounts of dictated information.
  8. Ability to foster inclusive and equitable relationships with colleagues and community members.
  9. Serve as an advocate for individuals of diverse backgrounds.

Qualifications and Experience Required

  1. High School diploma or equivalent.
  2. Availability to work onsite during standard business hours.
  3. Fluency in reading, writing, speaking, and comprehending English.
  4. Compliance with vaccination requirements.

Physical Requirements*

  1. Ability to sit or stand for extended periods.
  2. Normal or corrected vision and hearing capabilities.

*In compliance with the Americans with Disabilities Act of 1990 (ADA), it is essential to specify the physical, mental, and environmental conditions of the essential duties of the job.

Neighbor Health Center is an Equal Opportunity Employer, committed to building a diverse workforce dedicated to serving a varied patient population.

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