Scribe

The purpose of this position is to handle time-consuming clerical responsibilities for physicians during patient encounters. Scribes accompany a physician and directly observe patient encounters. This position accurately documents the events and decision-making in a manner that results in appropriate medical charting. The Medical Scribe also completes clerical activities necessary to assist with processing of physician orders for tests and medications. By accomplishing the time-consuming clerical duties that otherwise would be assigned to a physician, Scribes enable physicians to spend more time with individual patients and increase the overall flow of patients in the department. This role is relevant because physicians are highly trained for direct patient care and any clerical activity is a less efficient use of their health care expertise and efforts.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Performs routine clerical duties in accordance with established policies and procedures by:

• Receiving and greeting all patients and visitors in a professional manner and providing all reasonable assistance.
• Receiving telephone calls, taking and relaying messages accurately.
• Obtaining information from the patient to accurately complete the patient record for payment information, computer input, etc.
• Compiling a focused health record for the providers by locating and organizing disparate parts of each patient’s medical record including past medical records from the EMR systems as well as written charts and past diagnostic studies as needed.

Performs patient care duties as directed by the physician or nurse by:

• ???????Recording real time documentation in the EMR system for the provider such as history, physical, and patient course.
• Preparing patient for examination.
• Assisting physician and/or nurse with minor emergency or surgical procedures.
• Performing routine laboratory and EKG tests as ordered and collecting specimens for the lab.
• Administering and recording medication and injections as ordered.
• Interpreting physician's instructions to patients and providing instruction to patients.
• Checking and maintaining supply of stock to exam rooms.
• Cleaning and sterilizing instruments and equipment.
• Scheduling office or hospital procedures.
• Preparing procedure orders and accompanying data to be sent to the hospital for inpatient/outpatient studies.
• Managing and adjusting medication dosage under the direction of a physician and following up on patient compliance.
• Managing patient refills and ensuring that medications are dosed correctly and patient is taking them according to provider instructions.
• Preloading patient information into the EMR- including diagnostic testing, health maintenance, and past surgical history.
• Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present.
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
• Document any procedures performed by the physician.
• Identify any quality measures that are needed for patient and advise the physician.
• Enter the CPT code and ICD-10 diagnosis code that is verbalized by the provider.
• Serve as the patient advocate by communicating the patient’s needs and requests to the appropriate provider.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department:

• • Attending required meetings and participating in committees as requested.
  • Enhancing professional growth and development through in-service meetings and educational programs as approved.
  • Completing other job-related duties and projects as assigned.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated below are acquired through the successful completion of a high school diploma or equivalent is preferred. Must be a minimum of 17 years of age.

Knowledge & Skills

• Demonstrates knowledge of and competency in performing patient care procedures, observations, treatments and techniques utilized by facility.
• Requires ability to perform veni puncture.
• Demonstrates high level of interpersonal and communication skills necessary to consistently receive and greet visitors, clients, and staff members in a professional manner.
• Demonstrates well developed communication skills to communicate effectively and clearly to a variety of internal and external contacts.
• Requires knowledge of billing, office procedures and computer skills.
• Demonstrates analytical skills necessary to solve patient problems and interpret data.
• Promotes collaboration and innovation in the clinical services to ensure an interdisciplinary approach to improving health care delivery and the quality of patient care.
• Requires ability to perform EKG's and other procedures applicable to the practice.
• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English.
• Ability to spell, proofread and edit written text.
• Recognition of physical exam process and ability to record exam details.
• Organizational skills with focus on tracking patient care and improving patient flow.
• Have a solid understanding of quality measures and payer requirements for wellness.
• Be proficient in ICD-10 requirements for documentation purposes.

Working Conditions

• Works in a physician office environment.
• May require lifting or positioning of patients.
• Flexible hours and work schedule required.

Physical Demands

• Requires the physical ability and stamina to perform the necessary duties of the position.