WVUH-Scribe-86964

About the role

As an unlicensed member of the team, this position is responsible for documenting the physician’s or licensed independent practitioner’s dictation and/or activities into the medical record.

Minimum Qualifications

• High School Diploma or equivalent.
• State criminal background check and Federal (if applicable), as required for regulated areas.

Responsibilities

• Record history of present illness, past medical history, review of systems, medications, social history, family history, allergies or other elements of the patient chart as dictated by the physician or licensed independent practitioner.
• Accompany the physician or licensed independent practitioner in the patient examination area to transcribe a history and physical examination as given by the patient and provider.
• Document in the medical chart any procedures performed by the physician or licensed independent practitioner, or nurses.
• Transcribe consultations or discussions with family and/or the patient’s private physician or the on-call physician.
• Gather laboratory results, radiology results, medical records and other data for review by the physician or licensed independent practitioner; data must not be entered into the EMR, chart, or otherwise incorporated into the medical record until reviewed and approved by the physician or licensed independent practitioner.
• Continuously check on the progress of data to ensure the patient’s workup is complete so the physician or licensed independent practitioner can make treatment decisions.
• Make and answer calls for the physician or licensed independent practitioner; may not take medical data over the phone.
• Communicate waits and delays as directed by the RN or physician or licensed independent practitioner.
• Print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.

The Scribe may not provide verbal orders or relay verbal orders between the physician or licensed independent practitioner and other patient care providers. The physician or licensed independent practitioner must communicate orders directly to other care providers. Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Skills and Abilities

• Working knowledge of medical terminology and accepted abbreviations.
• Computer proficiency and ability to quickly learn new applications.
• Communication skills and the ability to coordinate and cooperate with multiple members of the health care team.
• Organizational skills with focus on tracking patient care and improving patient flow.
• Professional demeanor and recognition of privacy considerations for patients and families.
• Typing speed of 50 wpm preferred.
• Position is subject to core competencies and quality assurance monitoring.

Schedule

• Available to work clinic hours 8:00 AM to approximately 5:00 PM, Monday through Friday.
• Scheduled weekly hours: 36.