SCRIBE ORTHOPEDICS GRATIOT

Overview

The Scribe/Provider Facilitator is responsible for assisting assigned provider with documentation of the patient encounter, assisting healthcare providers with medical records, and helping set-up for procedures and obtaining items for the provider as needed. The Medical Scribe works alongside providers to improve workflow efficiency and support quality patient care.

Demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

• Follows the provider into patient rooms to document the encounter including the patient histories, physical examinations, assessments, treatment plans, and procedures during patient visits.
• Updates the patient chart to reflect any changes or corrections to the past medical history, surgical history, or social history as directed by the provider.
• Looks up information, x-rays, other studies, pending orders (excluding medications) from the patient chart for the provider to review and/or sign.
• Monitors all lab and imaging studies to ensure they return in a timely manner, follows it up to completion and informs provider of any delays.
• Document laboratory, imaging, and diagnostic test results, procedures as directed by providers, and any discussions with consultants or family members.
• Complete the ECC course, medical decision-making section, and as directed by the provider, for the provider to sign.
• Complete discharge instructions, including prescriptions as directed by the provider, for the provider to sign.
• Ensures all charting documentation is done in a timely manner, including importing all pertinent studies as directed by provider; accurate, legally sound, and captures all pertinent data for reimbursement.
• Communicate with provider when all results are back and the patient is ready for disposition.
• Obtains items for the provider, as needed and helps set-up for procedures, not including any direct patient contact.
• Obtains items for the patient as requested by the provider (i.e. water, food, or a blanket).
• Participate in regular QA reviews to assess good documentation skills and expectations.
• Participate in quality improvement initiatives and staff meetings.
• Maintains confidentiality of patient information according to established practice policies and government regulations, such as HIPAA.
• Maintains professional competency through ongoing training, continuing education activities, attending unit conferences, in-service programs, annual mandatory education, and competencies to meet the organization’s expectations.
• Performs other duties as assigned.

Qualifications

EDUCATION/EXPERIENCE

• High School diploma required.
• Currently working toward an advanced degree as a provider, provider 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.
• Familiar with medical terminology and basic anatomy preferred.

KNOWLEDGE/SKILLS/ABILITIES

• Maintains active knowledge of key billing, coding practices, department specific core measures and monitors for its application.
• Proficient in computer applications, including Microsoft Office and EMR.
• Knowledge of standard office equipment.
• Excellent oral and written communication skillswhen interacting with patients and families. Exemplary customer service skills.
• Demonstrated organizational skills and attention to detail.
• Protects and maintains the confidential nature of information and materials.
• Excellent time management, to achieve maximum productivity.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Remains flexible in cooperation with 24-hour staffing patterns and scheduling needs for provision of care for the special needs of the ECC department.
• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant hearing, near vision and midrange vision.
• Frequent lifting up to 10 lbs.
• Frequent standing, walking, sitting, far vision, depth perception, visual accommodation, color vision and field of vision.
• Occasional lifting, carrying, pushing, pulling, twisting, reaching, handling, feeling and talking.