CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Documents defined visit elements in a patient's electronic health record on behalf of a practitioner while being physically present in the room with the practitioner.

1. Documents or records the visit elements exactly as stated by the practitioner without interjecting his or her own observations or impressions.

2. Captures accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner.

3. Assists the practitioner in navigating the medial record.

4. Responds to various messages as directed by the practitioner.

5. Locates information for review (es: previous notes, reports, test results, and lab results)

6. Documents information into the medical record as directed by the practitioner.

7. Enters information in the electronic health record such as patient history, system review and physical examination, vital signs, procedures and treatments performed by the practitioner, care plan and medication lists, progress of lab, x-ray or other patient evaluation data, and practitioner dictated diagnoses, prescriptions and instructions.

8. Researches information requested by the practitioner.

9. Must make entries in the electronic health record using their own password/ access for all entries and must clearly include the name of the scribe and a legible signature/electronic signature, the name of the practitioner rendering services, qualifications of each person, and authentication of the scribe, including accurate date and time of service.

10. Supports practitioner in care documentation and data retrieval.

Education

Required: High School graduate, enrolled in college courses

Experience

1 year of experience in a similar position preferred

Skills

Preferred: Knowledge of Medical Terminology