Medical Scribe

Overview

Marin Community Clinics, founded in 1972, is today, a multi-clinic network with a wide array of integrated primary care, dental, behavioral, specialty and referral services. As a Federally Qualified Health Center (FQHC), we provide vital health services to almost 40,000 individuals annually in Marin County. The Clinics regularly receive national awards from the Health Resources and Services Administrations (HRSA). Our Mission is to promote health and wellness through excellent, compassionate care for all.

The medical scribe at Marin Community Clinics (MCC) is an integral part of MCC’s team care model, enhancing the quality and efficiency of our patient care. The medical scribe annotates 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 or specialist 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.

This positions requires working at different clinic locations in Marin County (San Rafael, Larkspur and Greenbrae), clinics are within close driving distance of each other.

Work schedule:

Monday through Friday 8:00am to5:00pm, evening shifts of 11:00am to 8:00pm and Saturday shifts with advanced notice.

Scribe-Specific Tasks and Duties:

• The primary role of the scribe is to assist the provider with documentation of each patient's clearly recording each patient's symptoms, history, physical exam, and documenting the diagnosis as well as treatment plans in the medical record during a clinic visit.
• At the start of the visits scribes checks the “document scribed” checkbox on the intake template at the top center.
• Accompanies the clinician into the patient examination area, or joins the appointment remotely by telephone, in order to transcribe a history and physical examination as given by the patient and provider.
• Under the direction of the provider, transcribes and places patient orders, including laboratory tests, radiology tests, referrals, etc.
• Documents any procedures performed by the provider or nurses in the EHR.
• Transcribes any consultation or discussions with family and/or the provider.
• 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.
• Scribe lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the provider.
• Scribe does not directly assist with patient care. The scribe documents orders generated by the provider.
• Scribe assists the provider and support staff with paperwork, telephone calls, faxing, and chart abstraction and may facilitate communication among the care team.
• Scribe is able to process portal communications and either task to appropriate member of the care team or get information from the provider to respond to the patient in a timely way.

The Medical Scribe does not perform the following:

• 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.
• 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; can’t touch the patient; can’t handle bodily fluids; can’t act independently without direct clinical oversight; conduct other duties while acting as the medical scribe; however, he/she may be asked to give patient paperwork during…