SCRIBE - NEUROSURGERY

Covenant HealthCare

Summary:
The role of the Scribe/Physician Facilitator includes assisting his or her assigned physician with documentation of the patient encounter, helping with patient flow by watching for results, helping set up for procedures and obtaining items for the physician as needed. He/She is not directly involved in patient care. The scribe demonstrates excellent customer service. Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant and the commitment to providing Extraordinary Care for Every Generation.

Responsibilities:

Familiar with medical terminology and basic anatomy. •Follows the physician into patient rooms to document the encounter including the history, review of systems, and physical exam. •Updates the patient chart to reflect any changes or corrections to the past medical history, surgical history, or social history as directed by the physician. •Looks up information from the patient chart for the physician to review. •Brings up x-rays or other studies for physician to review. •Monitors all lab and imaging studies to ensure they return in a timely manner. Let’s the physician know of any delays and follows it up to completion. •Let’s the physician know when all results are back, and the patient is ready for disposition. •Obtains items for the physician as needed and helps set up for procedures but will not have any direct patient contact (will not help hold a patient, etc.). •Obtains items for the patient as requested by the physician – like water, food, or a blanket. •Completes the visit note in a timely manner, including importing all pertinent studies as directed by the physician. •Documents procedures performed. •Documents any discussions with consultants or family members. •Under the direction of the physician, fill out the course of the visit, medical decision-making section, and diagnosis. •Ensures completed charting is accurate, legally sound, and captures all pertinent data for reimbursement. •Fill out discharge instructions, including prescriptions as directed by 100% •the physician, for the physician to sign. •Maintains active knowledge of key billing and coding practices