- Document the patient’s present illness, Review of Systems (ROS) and physical examination, vital sign and lab values, results of imaging studies, progress notes, continued care plan and medication list, final diagnosis as dictated by the physician.
- Document any procedures performed by the physician.
- Document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.
- At the conclusion of the physician’s patient encounter the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter.
- Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc.
- All orders for patient care must be communicated by the physician and not the Scribe.
Charge Entry Duties:
- Assign professional charges for admits, daily and discharge for inpatient, swingbed and observation patients.
- Verifies all procedures are documented and charges are captured.
- Extract information from nursing documentation for proper IM, IV, IVPB charge entry for all outpatient services.
- Communicate with nursing staff to meet infusion, injection guidelines for proper charge capture.
- Maintains complete confidentiality concerning care and patient records at all times.
- Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.
- Participate in ongoing educational opportunities as offered, as directed by Director.
- Be responsive to improvement opportunities in a positive manner.
- Communicate in a professional and respectful manner to the supervising physician and ancillary hospital staff.
- Performs other clerical job functions as necessary and/or requested by supervisor.
- High school graduate
- Minimum one-year and 2 shifts per week availability to work
- Excellent and legible penmanship
- Ability to multi-task and consistently communicate in a professional manner
- Completion of a medical terminology course or one year medical terminology experience in a clinical setting
- Punctuality and preparedness for all shifts and work-related activities
- Professional appearance is required. Must comply with dress code
- Ability to check and respond to all correspondence, including email, phone calls or text messages in a timely manner.
- Knowledge of ICD-10 CM/PCS and CPT guidelines
Preferred Position Qualifications:
- Healthcare student – physician, nursing, physician assistant, healthcare administration, etc.
- College level education including health or medical related courses
- Upper level knowledge of medical terminology
- Credentialed in ICD-10 CM/PCS and CPT with AHIMA or AAPC.
Physical Demands/Work Environment
The physical demands and work environment characteristics 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 perform the essential function.
Physical Demands: While performing duties of this job, the employee is required to sit, read and type for long periods of time. Must have the ability to lift, pull, push, and/or move up to 25 pounds.
Work environment: The noise level in the work environment is usually minimal, typical of a clinical office environment, primarily office exam rooms. Potential exposure to infectious diseases, blood and bodily fluids.