Clinical Documentation Specialist - Medical Scribe

Mission: Virginia Urology will provide access to individualized, quality, and compassionate urological care from a highly specialized and diverse teams while maintaining a fulfilling work environment.

Overall Objective:

Clinical Documentation Specialist / Medical Scribe prepares for patient visit, accurately gathers and documents healthcare data during examination and treatment of patients under the direction of a physician and clinical team. Using electronic medical records system (EMR), organizes healthcare data and reference data sources in support of clinic workflow to provide efficiency of clinical care while adhering to practice protocols and processes.

Responsibilities Include:

• Gathers information from multiple sources including recent health records from external providers and facilities in preparation for patient clinic visits.
• Under the supervision of a physician, abstracts patient information from the chart in preparation for the upcoming patient visit and enters the information into the EMR.
• Assists the physician and nurse during clinic visits by entering an accurate, complete record of the patient encounter in real-time into the EMR. This includes the patient’s medical history, complaint, symptoms, physical exam, physician’s assessment and treatment plan, post-visit documentation, and follow-up instructions. Entry is reviewed and approved by the provider.
• Under the provider’s supervision, coordinates electronic prescriptions, submits referrals to other medical specialists, and enters laboratory test and imaging orders to facilitate the provider’s treatment plan for the patient.
• Enhances clinic efficiency by escorting patients to exam rooms, checking out patients and making follow-up appointments at the conclusion of the clinic visit, and cleaning and restocking exam rooms between patients to maintain a clean, productive work environment.
• Imports charges from patient’s clinic visits into the EMR, including accurate diagnostic and procedure codes.
• Under the provider’s supervision, tracks lab and imaging tests and reports results to healthcare professionals.
• Perform other duties as assigned in support of clinical excellence, operational effectiveness and patient-centered care.