Description
Purpose:
The Scribe/Medical Writer is responsible for providing accurate documentation and summarization of the office visits and recommendations in the context of a patient chart while maintaining patient flow and communication regarding appointment status.
Responsibilities:
- Performs other duties as assigned, including but not limited to, answering phones, scanning, abstracting, checking patients in and out, helping with work ques, etc.
- Remains as close to physician as possible and limits time away from the physician and the patient.
- At times, guides patient to front desk after completion of exam and ensures proper follow-up appointments are made.
- Provides patient with assistants while they are exiting the exam room to expedite patient flow.
- Monitors examination room and any physical limitations that the patient may have
- Evaluates the condition of the exam room to ensure adequate supplies are in stock.
- Correctly summarizes and documents what the physician says during an examination, including but not limited to: proper charting of the examination, documenting additions to the chief complaint, assessment and recommendations for treatment (including justifications of decisions reached when appropriate).
- Learns the personality and preferences of each physician, recognizing differences and abiding by them when working with each particular physician.
- Accommodates the needs of the patient for the exam.
- Notifies physician of changes to the daily schedule, especially emergencies
- Enter charge information as designated by the physician
- Maintains an awareness of the patient?s verbal and non-verbal communication when the physician is providing instructions as it may necessitate the writer repeating information, providing written instructions, and/or patient educations materials for the patient to review at home.
- Becomes fluent in the exact requirements of each examination.
Qualifications
- Fluency in English
- High School Diploma and 4 years' experience in a medical office, medical transcription or billing/coding required.
- Or Associates degree or equivalent, and two years' experience in a medical office, medical transcription or billing/coding required.
- Basic of knowledge ICD-10 coding.
Licensure, Certifications, and Clearances:
CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire.
- Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
- Act 34 with renewal
- UPMC is an Equal Opportunity Employer/Disability/Veteran
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