Scribes will be responsible for accurately recording and documenting the details of physician or other LIP patient visits in the Veterans Health Information and Technology Architecture (VistA) and the Computerized Patient Record System (CPRS) hereafter collectively called the Electronic Health Record (EHR). Medical Scribe services will be provided in three (3) medical specialty areas including the Emergency Department (ED), Orthopedic Clinic, and Cardiology Clinic. The Scribe, as directed by the physician (or other clinical provider) will capture documentation, as instructed, into the VA's Computerized Patient Record System (CPRS). Performs all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the CPRS and electronic dictation system. Scribes do not have ANY patient care activities.
The general duties of a scribe may vary and can include:
*Ensures all verbal interactions and security of written, printed, and electronic files complies with HIPAA, HITECH, and PHI Privacy Laws
* Document all physician or other Licensed Independent Practitioner (LIP) patient appointment dialog in real time in the client's Computerized Patient Record System (CPRS) utilizing free text and/or designated templates making sure to use appropriate appointment and note titles
* Medical Scribes shall introduce themselves to the patient as working with physician X or other LIP. The Scribe will utilize standard client protocol to properly identify the patient prior to physician or other LIP treating patient.
* Researching information requested by the provider
* Documenting procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
* Documenting patient education and explanations of risks and benefits.
* Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
* Locate and retrieve any past medical history, lab results, imaging studies, EKGs and other pertinent reports or medical records for the physician or other LIP to review
* Medical specialties areas including the Emergency Department (ED), Orthopedic Clinic, and Cardiology Clinic.
* Veterans Health Information and Technology Architecture (VistA) and Computerized Patient Record System (CPRS) experience.
* Medical Scribes shall maintain professional conduct and the highest standard of integrity during interactions with physicians and other LIPs, patients, patients' families, and other healthcare professionals. Medical Scribes shall consistently communicate and treat others in a courteous, tactful and respectful manner.
* Participate in meetings and conferences related to patient care documentation and quality improvement as requested and deemed appropriate
* Experience as a medical scribe.
* Oral and written communication
* Comfortable with frequent communication with Veterans and all VA Medical Center personnel
* Proof of COVID-19 Vaccination
* Active Public Trust clearance
* Accredited Medical Scribe training
Veterans Health Information and Technology Architecture (Vista) and Computerized Patient Record System (CPRS) Experience.
Must be physically able to stand and walk from room to room for extended periods of time.
This is not necessarily an all-inclusive list of job-related responsibilities, duties, skills, efforts, requirements or working conditions as indicated by the client. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed as assigned. All job requirements are subject to possible revision to reflect changes in the position requirements or to reasonably accommodate individuals with disabilities. Some requirements may exclude individuals who pose a threat or risk to the health and safety of themselves or other employees. Employees will be required to follow other job-related duties as requested by their supervisor/manager (within guidelines and compliant with Federal and State Laws). Continued employment remains on an "at-will" basis.