Job Description

The duties of a Scribe are to document the clinician dictated patient history, physical examination, family, social, and past medical history, as well as document procedures, lab results, and any other information about the patient's encounter for the OASIS assessment. Scribes are not patient care providers but are part of the home health staff providing a care team approach for more timely and accurate OASIS assessments.

• Scribes are assigned to work with one clinician per OASIS.
• Scribes may enter information from the physician's history and physical and medication list into the assessment for the clinician's review.
• Scribes listen to the clinician's patient interview and examination.
• Scribes document the clinicians dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies, and OASIS assessments.
• Scribes document the clinician's examination findings and procedures as performed by the clinician.
• Scribes document the correct time of patient care-related activities, family communication, and patient re-examination.
• When the clinician concludes the patient's encounter, the clinician will review all documentation completed by the scribe, make any necessary amendments, and sign the chart. The assessing clinician is ultimately responsible for documentation of the patient's encounter.
• All orders for patient care must be communicated by the licensed clinician and not the Scribe.
• Scribes will upload completed OASIS into OperaCare and work with the clinician to resolve and correct the OASIS.
• Scribes will work within the EMR to apply the correct EBP care pathway designated by the customer to OASIS and return it to the customer.

Additional Responsibilities:

• Maintain and demonstrate an understanding of the team approach to patient care and documentation.
• Complete and present the medical record in collaboration with the supervising clinician.
• Pursue continuing education through clinical experiences to enhance skills and knowledge in promoting quality documentation.
• Participate in ongoing educational opportunities as offered by the employer.
• Attend regularly scheduled staff meetings.
• Be responsive to improvement opportunities in a positive manner
• Communicate professionally and respectfully to the assessing clinicians, management, and QA staff.

About you:

• Possess an PHRN license
• Ability to work inside EMR, competency in typing
• Excellent and legible penmanship
• Ability to multi-task and consistently communicate in a professional manner
• Proficiency in English speaking and writing
• Punctuality and preparedness for all shifts and work-related activities
• Professional appearance is required. Must comply with dress code
• Ability to check and respond to all correspondence, including email, phone calls, or text messages promptly
• Observes and complies with home health Safe Practices, safety policies, and emergency procedures.
• Normal vision and hearing or normal when corrected
• Ability to multi-task and perform duties under pressure
• Adequate knowledge of computer usage and ability to tolerate viewing on computer monitors for extended periods

Job Type: Full-timeSchedule:

• 8 hour shift

Supplemental Pay:

• 13th month salary

Ability to commute/relocate:

• Makati City: Reliably commute or planning to relocate before starting work (Required)