SCRIBE - ORTHOPEDICS

Responsibilities

• Familiar with medical terminology and basic anatomy.
• Follows the physician into patient rooms to document the encounter including the history, review of systems, and physical exam.
• Updates the patient chart to reflect any changes or corrections to the past medical history, surgical history, or social history as directed by the physician.
• Looks up information from the patient chart for the physician to review.
• Buys up x-rays or other studies for physician to review.
• Makes sure all lab and imaging studies return in a timely manner. Let’s the physician know of any delays and follows it up to completion.
• Lets the physician know when all results are back, and the patient is ready for disposition.
• Obtains items for the physician as needed and helps set up for procedures but will not have any direct patient contact (will not help hold a patient, etc.).
• Obtains items for the patient as requested by the physician – like water, food, or a blanket.
• Completes the visit note in a timely manner, including importing all pertinent studies as directed by the physician.
• Documents procedures performed.
• Documents any discussions with consultants or family members.
• Under the direction of the physician, fills out the course of the visit, medical decision-making section, and diagnosis.
• Ensures completed charting is accurate, legally sound, and captures all pertinent data for reimbursement.
• Fills out discharge instructions, including prescriptions as directed by 100% the physician, for the physician to sign.
• Maintains active knowledge of key billing and coding practices.

Qualifications

• Educational/Experience Requirements: High School diploma required. Currently working toward an advanced degree as a physician, physician assistant, or nurse OR must have completed a scribe, medical terminology, or electronic medical record training program/course OR prior experience as a Medical Scribe. Maintain good documentation skills based on regular QA reviews.
• Attending unit conferences, required competencies, in-service programs, annual mandatory education, competencies and continuing education activities to meet the organization’s expectations.
• Knowledge/Skills/Abilities: Basic computer skills. Knowledge of standard office equipment. Familiar with medical terminology and basic anatomy. Excellent oral and written communication skills. Demonstrated organizational skills. Sound judgment in handling confidential or sensitive issues and material. Excellent time management, to achieve maximum productivity. Attentive to detail.