UCLA Health Medical Scribe - Ophthalmology in Los Angeles, California
Under the direction of physicians: Assist physicians in charting (electronic or paper) by recording the documentation of an accurate, concise, and complete patient history and review of systems based on patient-physician interactions, recording a physical exam based on a physician's dictation, accurately transferring lab and radiology results from the electronic system or as dictated by physicians, or other department staff, recording progress or procedures notes, clinical impression, plan and follow-up.
Under the direction of physicians: Communicate with other hospital personnel through face-to-face conversations, paging, phone calls, and e-mails.
Under the direction of physicians: Assist in recording the documentation of patient admission, transfer, or discharge plan and follow-up.
Ensure accurate documentation to allow for full billing opportunities with CMS
Navigate EMR to look up patients' previous medical records, prior labs results, etc. Assist in real-time and retrospective chart auditing which includes assessing all department charts for completeness and sending incomplete charts back to the appropriate physician(s).
Under direction of physicians, pend orders and referrals in CareConnect for MD signature.
Print and review After Visit Summary with patients
Copy and provide educational materials to patients
File and store medical records for future consultations
Assist supervisor with other administrative duties as needed.
Assist with the training of new Medical Scribe hires.
Assist with development of standardized care pathways by way of managing smart phrases and thorough knowledge of clinical operations.
Other duties, as assigned.
May convert to Career.Qualifications
Ability to perform under the pressure of frequent interruptions and distractions.
Ability to proofread very detailed materials and monitor work accurately.
Strong interpersonal skills to effectively and diplomatically interact with others.
Demonstrated excellent verbal and written communication skills.
Ability to speak clearly and distinctly using appropriate vocabulary and grammar to obtain and convey information.
Skill in working independently and following through on assignments with minimal supervision.
Ability to maintain equanimity in the face of resistance, indifference or hostility.
Knowledge and skill in using various computer programs such as Word, Excel, PowerPoint, Outlook email and database software.
Ability to establish and maintain cooperative working relationships with co-workers, faculty, residents, nurses, students, University representatives, patients and the public.
Willingness to work a flexible schedule which will include evenings, nights, weekends, and holidays.
Ability to organize and track multiple records and requests and follow through in a timely manner.
Ability to handle confidential material while protecting its strict confidentiality.
A minimum of two years of scribe or related physician support experience
Prior experience with training new Physician Support Assistants
Previous experience with electronic medical records such as Medhost, EPIC, Cerner, etc.
Detailed knowledge of medical terminology and the ability to distinguish different exams and medical diagnoses is required.
Knowledge of E&M codes and the level of documentation necessary for each billing level
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