WVUH-Scribes-86964

WVU Medicine; Bridgeport (WV); On-site; USD 17,000 - 25,000; Part time

Job summary

WVUH West Virginia University Hospitals is seeking a detail-oriented Medical Scribe to document physician and licensed practitioner dictation into the medical record. The role supports continuity of care by accurately recording HPI, ROS, medications, and patient history while working within patient care teams.

The candidate will accompany providers, document procedures, and handle data gathering for lab and radiology, ensuring data is reviewed before entry.

Qualifications

• High School Diploma or equivalent.
• Background check as required for regulated areas.

Responsibilities

• Document physician or LIP dictation and activities into the medical record.
• Transcribe history and physicals as given by patient and provider.
• Record procedures performed by physician or nurses.
• Transcribe consultations or discussions with family and/or physician.
• Gather laboratory and radiology results for physician review and update.

Skills

Medical terminology

Typing speed 50 wpm

Communication skills

Organizational skills

Privacy/compliance awareness

EMR systems familiarity

Education

High School Diploma or equivalent

Tools

EMR systems

Job description

Welcome! We’re excited you’re considering an opportunity with us!

Below, you’ll find other important information about this position.

As an unlicensed member of the team, this position is responsible for documenting the physician’s or licensed independent practitioner’s dictation and/or activities into the medical record.

Minimum Qualifications

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• High School Diploma or equivalent.
• State criminal background check and Federal (if applicable), as required for regulated areas.

CORE DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• For history of present illness, past medical history, review of systems, medications, social history, family history, allergies or other elements of the patient chart: The physician or licensed independent practitioner will elicit the information as usual and Scribes will record the information in the chart for approval.
• The Scribe may accompany the physician or licensed independent practitioner in the patient examination area in order to transcribe a history and physical examination as given by the patient and physician or licensed independent practitioner.
• The Scribe documents in the medical chart any procedures performed by the physician or licensed independent practitioner, or nurses.
• The Scribe transcribes any consultations or discussions with family and/or the patient’s private physician or the on-call physician.
• Scribes may gather laboratory results, radiology results, medical records and other data for review by the physician or licensed independent practitioner. Data should not be entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician’s or licensed independent practitioner.
• Scribes must continuously check on the progress of this data in order to get the patient’s workup complete so that the physician or licensed independent practitioner is able to make treatment decisions.
• The Scribe may not provide verbal orders or relay verbal orders between the physician or licensed independent practitioner and other patient care providers. The physician or licensed independent practitioner must communicate orders directly to other care providers.
• Scribes can make and answer calls for the physician or licensed independent practitioner, however Scribes may not take medical data over the phone.
• Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.
• Scribes can communicate waits and delays as directed by the RN or physician or licensed independent practitioner.
• Scribes may print the physician’s or licensed independent practitioner process at the physician or licensed independent practitioner’s direction.

PHYSICAL REQUIREMENTS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Skills And Abilities

• Working knowledge of medical terminology and accepted abbreviations.
• Computer proficiency and ability to quickly learn new applications.
• Communication skills and the ability to coordinate and cooperate with multiple members of the health care team.
• Organizational skills with focus on tracking patient care and improving patient flow.
• Professional demeanor and recognition of privacy considerations for patients and families.
• Typing speed of 50 wpm preferred.
• Position is subject to core competencies and quality assurance monitoring.

Additional Job Description

Must be available Tuesday and Thursday 8A-5P.

Scheduled Weekly Hours

16

Shift:

United States of America (Non-Exempt)

Company

WVUH West Virginia University Hospitals

Cost Center

8815 UHA Scribes

Address

327 Medical Park Drive

Bridgeport

West Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.