SCRIBE

Carilion Clinic•Lexington, VA

6d•$15 - $21

About The Position

The Scribe facilitates and assists in completing physicians’ medical records and patient documentation in a professional and timely manner. The Scribe accompanies a physician during patient-care duties throughout each shift and updates the medical record in real time, transcribing physical examination details and chart elements. This includes incorporating results from laboratory and imaging tests and medications ordered by the physician. The Scribe may also document consultations between physicians, family members, or other physicians regarding a patient’s case. The role includes reminding physicians about the progress of laboratory, X-ray, and other patient evaluation data and documenting results so the patient’s workup is complete and the physician can make informed treatment decisions. The Scribe documents procedures performed by physicians and other healthcare professionals, including nurses and physician assistants, and may assist in initiating pages to consultants. The position requires mastering EPIC EMR and the PACS imaging system. Additional duties may vary by site or department. When working with PPEs, the Scribe assists with mask drop-off and retrieval, bleach changes, PPE replacement, and employee exposure logs. Documentation specialists implement timely referrals to physician advisors. The role may also involve collecting data about activities and improvements, performing pre-billing reviews of clinical documentation, and maintaining awareness of changes in 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, typing, 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 chart elements, and incorporate laboratory results, imaging results, and medications ordered by physicians.
Document physician consultations with family members or other physicians when needed.
Remind physicians about the status of laboratory, X-ray, and other patient evaluation data, and document results in patient charts.
Document procedures performed by physicians and other healthcare professionals, including nurses and physician assistants.
Assist in initiating pages to consultants for physicians.
Use the EPIC EMR and PACS imaging system.
Perform other duties based on site-specific or department-specific requirements.
When working with PPEs, assist with mask drop-off and retrieval, bleach changes, PPE replacement, and employee exposure logs.
As a documentation specialist, implement timely and appropriate referrals to physician advisors.
Collect data showing activities performed and improvements made, as needed.
Perform pre-billing reviews of clinical documentation, as needed.
Maintain awareness of changes in healthcare coding, billing, and the business of medicine, including applicable CMS updates.