Scribe - Carilion New River Valley Medical Center

Carilion Clinic•Christiansburg, VA

1d•Onsite

About The Position

The Scribe facilitates and assists in the completion of the physician's medical records and patient documentation in a professional and timely manner. The Scribe accompanies a physician through the duties of patient care during the course of each work shift, while updating the medical record in real time. This includes transcribing details of the physical exam and elements of the chart, assimilating results from lab tests, imaging tests, or medications ordered by the physician. A scribe may also be present to record a physician's consultations with family members or other physicians about a specific patient's case. The role involves reminding the physician on the progress of lab, X-ray, or other patient evaluation data and transcribing results into patient charts to ensure a complete patient workup for sound treatment decisions. The Scribe documents procedures performed by the physician or any other healthcare professional, including nurses and physician assistants, and may assist in initiating pages to consultants. Key responsibilities include mastering the use of the EPIC EMR and PACS imaging system, and performing other site-specific or department-specific duties. When working with PPEs, the Scribe will assist with mask drop off and retrieval, bleach changes, replacement of PPE, and employee exposure logs. If working as a documentation specialist, the Scribe will implement appropriate and timely referrals to physician advisors, collect data on activities and improvements, and may perform pre-billing reviews of clinical documentation. The Scribe is expected to maintain awareness of the business of medicine and changes in coding and billing in a healthcare setting, including Value Based Medicine, Readmission Reduction Programs, provider updates, and CMS updates impacting billing, documentation, and coding.

Requirements

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

Responsibilities

Facilitates and assists in the completion of the physician's medical records and patient documentation in a professional and timely manner
Accompanies a physician through the duties of patient care during the course of each work shift, while updating the medical record in real time
Transcribing details of the physical exam and elements of the chart
Assimilating results from any lab tests, imaging tests, or medications ordered by the physician
Recording a physician's consultations with family members or other physicians about a specific patient's case
Reminds physician on the progress of lab, X-ray, or other patient evaluation data and transcribing the results into patient charts so that a patient's workup is complete and the physician can make sound treatment decisions
Documents procedures performed by the physician or any other healthcare professional, including nurses and physician assistants
May assist in initiating pages to the consultants for the physician
Masters the use of the EPIC EMR, and the PACS imaging system
Performs other duties as required based upon site-specific or department specific requirements
When working with PPEs will assist with mask drop off and retrieval, bleach changes, replacement of PPE and employee exposure logs
If working as documentation specialist will implement appropriate and timely referrals to physician advisors
May collect data showing activities performed and improvements made
May perform pre-billing reviews of clinical documentation
Demonstrates a willingness to maintain awareness of the business of medicine and changes in coding and billing in a health care setting including, but not limited to, Value Based Medicine, Readmission Reduction Programs, provider updates and the business of medicine directly impacting physician practices that may include updates from CMS that may impact billing, documentation and coding