Ophthalmic Scribe

Description

Summary

Accompany the physician during patient exams and transcribe exam notes as dictated by physician into the electronic medical records system. Work to ensure an accurate and complete medical record for each patient and help facilitate patient flow.  Perform work with a focus on effective communication with the patient, coworkers, and the physician.  Demonstrate cooperation with coworkers while striving to ensure the highest level of patient care and “customer service,” always representing EHN in a professional manner.

Supervisory Responsibilities

This position does not have supervisory responsibility but will provide guidance to employees and/or assist with orientation and training of new employees of the work group.

Primary Duties and Responsibilities

• Prepares appropriate equipment for each exam if needed.
• Assists physician during patient exam by transcribing comprehensive notes relating to:
  • History
  • Personal information
  • Medical condition
  • Physician’s assessment
  • Diagnostic findings
  • Lab and test results
  • Consultations with other providers
  • History of present illness
  • Chief complaint including all symptoms and diagnosis.
• Updates medication module
• Able to process cultures and enter Alerts as needed.
• Documents all procedures performed by the physician.
• List all proper diagnosis and symptoms as well as follow-up instructions and prescriptions as instructed by the physician. 
• Follows up to implement the physician’s instructions for patient care/treatment:
  • Starts the surgery template.
  • Tasks and transfers relevant information to the surgery scheduler, Special Testing, or other group for follow up.
  • Electronically sends prescriptions.
• Prints and provide paper prescriptions, optical and CL prescriptions and patient education.
• Makes 1-year diabetic exam or other follow up appointments while the patient is in the room if provider requests.
• Prints and mail physician and patient correspondence.
• Ensures exam notes and other documentation in EHR are clear, accurate and complete.
• Helps to maintain cleanliness and orderliness of exam rooms during the workday.
• Assists with patient flow throughout the office.
• Assist with exams and procedures as instructed, such as instilling drops and performing AR as needed.       
• Follow up and complete all related paperwork, i.e., ensure the fee tickets are appropriately marked and delivered to the front desk; ensure that the faxes sent from EHR have been sent, get the patient scheduled for next visit.
• Complete referrals to outside providers
• Walks the patient to the optical desk to obtain their prescription or to the front desk to make additional follow up appointments as needed.
• Assists provider with other correspondence or communication as needed (notifying patients of normal lab/radiology results, return calls as requested by patients, sends Tasks to Surgery Coordinator or Special Testing, etc.)
• Effectively communicates with patients, coworkers, and doctors; shares information appropriately and completes the communication circle with follow-up as needed; communicates in a positive, upbeat manner while refraining from complaining, gossiping, or engaging in conversations of a negative tone. 

• Perform work in compliance with company policy, department procedures and regulatory requirements, including HIPPA and OSHA.

Secondary Functions

• Other duties which may be necessary or desirable to serve the patient and support the success of the department or the company overall.

Qualifications

Education and/or Experience; Certificates, Licenses, and Registrations (Minimum Requirements)

• High school diploma or equivalent.
• Minimum of 6 months experience as a medical scribe preferred.
• A minimum of one (1) year experience preferred.
• An equivalent combination of experience, training and certification that would provide the knowledge, skills and abilities required for the successful performance of the essential job duties.

Necessary Knowledge, Skills, and Abilities

• Knowledge of medical terminology as it relates to the anatomy and diseases of the eye.

• Strong written and verbal communication skills.
• Ability to actively listen.
• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English.
• Ability to spell proofread and edit written text.
• Keyboard proficiency (approximately 70 words per minute).
• Ability to operate a personal computer and related software applications.
• Strong attention to detail.
• Ability to problem solve under pressure.
• Ability to communicate and interact professionally with others.
• Understanding of and commitment to appropriate protection of confidential patient information.

• Ability to work a flexible work schedule, including evenings and weekends, and a willingness to rotate to various worksites as needed.

Physical Demands / Work Environment

• Majority of work is performed in a general medical office environment. Exposure to moderate levels of noise in a well-lit, well-ventilated, and moderately paced environment; some work is performed in dimmed lighting.
• This position requires manual/finger dexterity as necessary to perform daily job duties.
• Occasionally required to stand and/or walk for extended periods of time.
• Occasionally required to reach with hands and arms; lift, push, pull and/or carry objects up to 20 pounds.

Reasonable Accommodations

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.