Scribe - Surgery
Scribe - Surgery
Job CategoryAllied Health
Shift1 - Day Shift
Assists provider with documentation and efficiency management. Observes the provider during patient encounters and performs documentation on the provider’s behalf. Under the direction of the provider, the Scribe enters information into the patient’s electronic or written chart. Assists in maintaining that the scribed chart accurately reflects all work performed by the provider.
Chart in real-time as the provider assesses and examines the patient.
Document the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultations.
Record provider dictated diagnoses, prescriptions and instructions for patient follow-up.
Locate and obtain past medical histories, previous charts, past results, and studies.
Transcribe ancillary test results and their interpretations.
Check on the progress of labs, imaging studies, and other patient data.
Retrieve and display current and past EKGs and imaging films (e.g. Xrays for the provider to review and record provider’s interpretation (if applicable).
Comply with all national and local PHI laws including in HIPAA and HITECH.
Comply with all facility, department, company policies and procedures.
Performs related duties as assigned.
EDUCATION: High school diploma or general education degree (GED).
EXPERIENCE: Preferred two (2) years of related Scribe experience, preferably in an acute care setting.
LICENSURE OR CERTIFICATION: None required
KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of basic ICD 10 documentation requirements
Knowledge of medical terminology
Knowledge of medicolegal documentation
Knowledge of Evaluation and Management (E&M) billing basics
Skill in physical exam findings
Skill in efficiency management
Demonstrated skill in
Ability to navigate electronic charge capture in EPIC EMR system
Ability to work independently with minimal or no supervision.
Ability to work under pressure with time constraints.
Ability to concentrate and pay attention to detail.
Ability to demonstrate excellent verbal and written communication skills
Ability to type a speed of 50+ WPM