Scribe

Job Description

Job Description

Position Summary/Scope of Responsibility

The Centers for Advanced Orthopaedics LLC (CAO) is one of the nation’s largest Orthopaedics practices, owned and operated by physicians, with over 60 locations across Maryland, Northern Virginia, and the District of Columbia. With approximately 2,000 employees, working in 28 Divisions, CAO is a growing business with revenues of approximately $250 Million. CAO is committed to be the Orthopaedics provider of choice for our patients; partner of choice for payors and health systems; and employer of choice by attracting and retaining a talented workforce.

The Scribe prepares and assembles medical record documents/charts for physicians and prepares and sends all documentation to physicians for review and approval. The Scribe ensures medical record compliance and complies with hospital and medical facility policies. Responsible for updating patient history, physical exams, and other pertinent health information and monitoring the duration of basic lab results and screening procedures.

Duties include, but are not limited to:

1. Prepares and assembles medical record documentation/charts for physician(s).
2. Accompanies physician(s) during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
3. Ensures medical record compliance by self-documentation attestation.
4. Updates patient history, physical exam, and other pertinent health information.
5. Prepares and sends all documentation to physician(s) for review and approval via authentication of detailed data entry and facility-specific procedures.
6. Monitors and documents the duration of basic lab results, radiographic studies, and screening procedures as dictated by the physician(s).
7. Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
8. Refers all requests related to patient care to the responsible physician or nursing staff.
9. Performs other duties as assigned.

Required Education & Experience

• High School Diploma or Equivalent.
• Skilled in operating various medical record software and hardware, word-processing, and database software programs.
• Knowledge of medical terminology and human anatomy preferred.
• Minimum of 60 WPM preferred.

Competencies/Required Skills & Abilities

• Strong Interpersonal Skills - Ability to develop relationships and collaborate and influence in a decentralized organization. 
• Strong skills in record keeping and typing/word processing at 60 WPM.
• Demonstrated ability to organize, prioritize, and manage multiple tasks in a dynamic environment with a proven track record of results. 
• Strong oral and written communication skills with excellent self-discipline and patience. 
• Able to work independently. 
• Excellent time management, organization, and administrative support skills. 
• Must be able to read, write, speak, understand, and communicate in the English language.

Physical Demands

• Must be able to sit for long periods of time and lift up to 25 pounds.  
• Must be able to use appropriate body mechanics techniques when performing desk duties.  
• Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting, and sitting.
• Adequate hearing to perform duties in person and over telephone.
• Must be able to communicate clearly to patients in person and over the telephone.
• Visual acuity adequate to perform job duties, including reading materials from printed sources and computer screens.