Summary:

Accompany the physician during patient exams and transcribe exam notes as dictated by physician into the electronic medical records system. Work to ensure an accurate and complete medical record for each patient and help facilitate patient flow. Perform work with a focus on effective communication with the patient, coworkers and the physician. Demonstrate cooperation with coworkers while striving to ensure the highest level of patient care and “customer service,” representing EHN in a professional manner at all times.

Supervisory Responsibilities:

This position does not have supervisory responsibility but will provide guidance to employees and/or assist with orientation and training of new employees of the work group.

Essential Functions:

• Assist physician during patient exam by transcribing comprehensive notes relating to patients history, personal information, medical condition, physician’s assessment, diagnostic findings, lab and test results, consultations with other providers, presence of condition, etc.
• Document all procedures performed by the physician.
• List all proper diagnosis and symptoms as well as follow-up instructions and prescriptions as instructed by the physician.
• Update medication module.
• Ensure all results and outside documentation are in EHR.
• Ensure exam notes and other documentation in EHR are clear, accurate and complete.
• Follow up to implement the physician’s instructions for patient care/treatment, i.e. start the surgery template; task and transfer relevant information to the surgery scheduler; task medical records to schedule special tests; electronically send prescriptions.
• Print and provide paper prescriptions, optical and CL prescriptions and patient education
• Print and mail physician and patient correspondence.
• Ensure work area and exam rooms are clean, orderly, stocked and properly prepped for each patient.
• Prepare appropriate equipment for each exam.
• Assist with exams and procedures as instructed, such as instilling drops and performing AR as needed.
• Follow up and complete all related paperwork, i.e. ensure the fee tickets are appropriately marked and delivered to the front desk; ensure that the faxes sent from EHR have been sent.
• Complete referrals to outside providers
• Make 1-year diabetic exam appointments while the patient is in the room.
• Assist the technicians to ensure the patient flow is efficient.
• Walk the patient to the optical desk or the front desk to make a follow up appointment.
• Demonstrate team values through cooperation and consideration of coworkers; foster goodwill among coworkers by providing assistance when needed and sharing information that helps others do their jobs; interact with tact, courtesy and diplomacy.
• Effectively communicate with patients, coworkers and doctors; share information appropriately and complete the communication circle with follow-up as needed; communicate in a positive, upbeat manner while refraining from complaining, gossiping, or engaging in conversations of a negative tone.
• Perform work in compliance with company policy, department procedures and regulatory requirements, including HIPPA and OSHA.

Secondary Functions:

• Other duties which may be necessary or desirable to serve the patient and support the success of the department or the company overall.

Physical Demands / Work Environment:

• Majority of work is performed in a general medical office environment. Exposure to moderate levels of noise in a well-lit, well-ventilated and moderately paced environment; some work is performed in dimmed lighting.
• This position requires manual/finger dexterity as necessary to perform daily job duties.
• Occasionally required to stand and/or walk for extended periods of time.
• Occasionally required to reach with hands and arms; lift, push, pull and/or carry objects up to 20 pounds.

Reasonable Accommodations:

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience; Certificates, Licenses, and Registrations (Minimum Requirements):

• High school diploma or equivalent.
• Minimum of 6 months experience as a medical scribe preferred.
• Must have Ophthalmic Scribe (OSC) or Ophthalmic Assistant (COA) certification or have the ability to obtain certification within 12 months of being hired; must be able to complete the Home Study Course for COA certification within 90 days of being hired.
• A minimum of one (1) year experience preferred.
• An equivalent combination of experience, training and certification that would provide the knowledge, skills and abilities required for the successful performance of the essential job duties.

Necessary Knowledge, Skills and Abilities:

• Knowledge of medical terminology as it relates to the anatomy and diseases of the eye.
• Strong written and verbal communication skills.
• Ability to actively listen.
• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
• Ability to spell proofread and edit written text.
• Keyboard proficiency (approximately 70 words per minute).
• Ability to operate a personal computer and related software applications.
• Strong attention to detail.
• Ability to problem solve under pressure.
• Ability to communicate and interact professionally with others.
• Understanding of and commitment to appropriate protection of confidential patient information.
• Ability to work a flexible work schedule, including evenings and weekends, and a willingness to rotate to various worksites as needed.