Scribe

WVU Medicine
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.

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.
  • Communicate waits and delays as directed by the RN or physician or licensed independent practitioner.
  • Print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.
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