Scribe

WVU Medicine•Institute, WI

1d•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.
Position is subject to core competencies and quality assurance monitoring.

Nice To Haves

Typing speed of 50 wpm preferred.

Responsibilities

For history of present illness, past medical history, review of systems, medications, social history, family history, allergies or other elements of the patient chart: The physician or licensed independent practitioner will elicit the information as usual and Scribes will record the information in the chart for approval.
The Scribe may accompany the physician or licensed independent practitioner in the patient examination area in order to transcribe a history and physical examination as given by the patient and physician or licensed independent practitioner.
The Scribe documents in the medical chart any procedures performed by the physician or licensed independent practitioner, or nurses.
The Scribe transcribes any consultations or discussions with family and/or the patient’s private physician or the on-call physician.
Scribes may 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.
Scribes must continuously check on the progress of this data in order to get the patient’s workup complete so that the physician or licensed independent practitioner is able to make treatment decisions.
The Scribe 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.
Scribes can make and answer calls for the physician or licensed independent practitioner, however Scribes may not take medical data over the phone.
Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.
Scribes can communicate waits and delays as directed by the RN or physician or licensed independent practitioner.
Scribes may print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.