Scribe - Carilion Orthopedic Surgery

Carilion Clinic•Roanoke, VA

6d•Onsite

About The Position

The Scribe facilitates and assists with completing physicians’ medical records and patient documentation in a professional and timely manner. The Scribe accompanies a physician during patient-care duties throughout each work shift and updates the medical record in real time. This includes transcribing physical examination details and chart elements, incorporating results from laboratory and imaging tests and medications ordered by the physician, and recording consultations with family members or other physicians when needed. The Scribe monitors the progress of laboratory, X-ray, and other patient-evaluation data, enters results into patient charts, and documents procedures performed by physicians and other healthcare professionals. The role may include initiating pages to consultants for the physician, using the EPIC EMR and PACS imaging system, and completing other site- or department-specific duties. Depending on the assignment, the Scribe may assist with PPE-related tasks, implement referrals to physician advisors, collect data on activities and improvements, and conduct pre-billing reviews of clinical documentation. The Scribe is expected to maintain awareness of changes in healthcare coding, billing, and the business of medicine, including Value Based Medicine, Readmission Reduction Programs, provider updates, and relevant CMS updates.

Requirements

Associate's degree or equivalent required.
1–2 years of experience working with the public in a healthcare setting required.
Excellent PC and typing skills required.
Excellent interpersonal and verbal communication skills required.
Familiarity with medical terminology required.

Responsibilities

Accompany physicians during patient-care duties and update medical records in real time.
Transcribe physical examination details and other chart elements.
Incorporate laboratory and imaging results and medications ordered by the physician into the medical record.
Record physician consultations with family members or other physicians when needed.
Track the progress of laboratory, X-ray, and other patient-evaluation data and enter results into patient charts.
Document procedures performed by physicians and other healthcare professionals, including nurses and physician assistants.
Initiate pages to consultants for the physician when needed.
Use the EPIC EMR and PACS imaging system.
Perform other duties according to site- or department-specific requirements.
When working with PPE, assist with mask drop-off and retrieval, bleach changes, PPE replacement, and employee exposure logs.
When working as a documentation specialist, implement appropriate and timely referrals to physician advisors.
Collect data showing activities performed and improvements made, as applicable.
Perform pre-billing reviews of clinical documentation, as applicable.
Maintain awareness of healthcare coding and billing changes and business developments that may affect physician practices and documentation.