Scribe

WVU Medicine•Wheeling, IL

23h•Onsite

About The Position

As an unlicensed member of the team, this position is responsible for documenting the physician’s or licensed independent practitioner’s dictation and/or activities into the medical record.

Requirements

High School Diploma or equivalent.
State criminal background check and Federal (if applicable), as required for regulated areas.
Working knowledge of medical terminology and accepted abbreviations.
Computer proficiency and ability to quickly learn new applications.
Communication skills and the ability to coordinate and cooperate with multiple members of the health care team.
Organizational skills with focus on tracking patient care and improving patient flow.
Professional demeanor and recognition of privacy considerations for patients and families.
Ability to work their fair share of nights, weekends, and holidays.

Nice To Haves

Typing speed of 50 wpm preferred.

Responsibilities

Record patient chart information such as history of present illness, past medical history, review of systems, medications, social history, family history, allergies, or other elements, as dictated by the physician or licensed independent practitioner, for approval.
Accompany the physician or licensed independent practitioner in the patient examination area to transcribe a history and physical examination as given by the patient and physician or licensed independent practitioner.
Document procedures performed by the physician or licensed independent practitioner, or nurses, in the medical chart.
Transcribe consultations or discussions with family and/or the patient’s private physician or the on-call physician.
Gather laboratory results, radiology results, medical records, and other data for review by the physician or licensed independent practitioner. Data should not be entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician’s or licensed independent practitioner.
Continuously check on the progress of gathered data to ensure the patient’s workup is complete so that the physician or licensed independent practitioner is able to make treatment decisions.
May not provide verbal orders or relay verbal orders between the physician or licensed independent practitioner and other patient care providers. The physician or licensed independent practitioner must communicate orders directly to other care providers.
Can make and answer calls for the physician or licensed independent practitioner, however may not take medical data over the phone.
May not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.
Can communicate waits and delays as directed by the RN or physician or licensed independent practitioner.
May print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.