Scribe / Ambulatory Surgery Center and Clinic

Job Summary

Claris Vision, LLC, is hiring a Scribe for our Ambulatory Surgical Center and for our Ophthalmology Clinic. The person in this role will split their time between the ASC and the clinic. The Scribe at the Ambulatory Surgery Center provides real-time documentation support to anesthesia providers (CRNAs and/or anesthesiologists) throughout the perioperative process. The scribe promotes accurate, complete, and timely anesthesia records in compliance with AAAHC standards, Massachusetts Department of Public Health (105 CMR 140.000), and CMS Conditions for Coverage (42 CFR Part 416).

The Anesthesia Scribe functions in a non-clinical, non-licensed role, and does not provide direct patient care. All documentation is entered under the direction, review, and authentication of a licensed anesthesia provider.

On the clinic side, the Scribe will document and update records in the EMR at the direction of the Ophthalmologist. 

This position is located onsite in Dartmouth, MA. 

Duties and Responsibilities

Clinical Documentation Support

• Documents anesthesia care in real time in the EMR under direct provider direction 
• Accurately captures: 
  • Pre-anesthesia evaluation elements (as dictated) 
  • Intraoperative physiological data, medications, and interventions 
  • Anesthesia start/stop times and case events 
  • Post-anesthesia and handoff documentation 
• Ensures anesthesia record completeness prior to finalization 

AAAHC Survey-Ready Compliance & Documentation Standards

The Anesthesia Scribe supports facility compliance with AAAHC standards, including but not limited to Chapter 12 (Anesthesia Services) and Chapter 5 (Clinical Records & Health Information):

Documentation Integrity

• Ensures entries are: 
  • Accurate, complete, legible, and time-sequenced 
  • Entered contemporaneously (real-time) during the procedure 
• Clearly identifies all entries as “scribed for [provider name]” in accordance with documentation best practices 

Authentication & Supervision

• All scribed entries must be: 
  • Reviewed, verified, and authenticated by the anesthesia provider (CRNA or anesthesiologist) 
  • Finalized in accordance with facility policy and AAAHC expectations for timely authentication of medical records 
• The anesthesia provider retains full responsibility for the content, accuracy, and clinical validity of the record 

Anesthesia Record Compliance (AAAHC Chapter 12)

• Supports required anesthesia documentation elements, including: 
  • Pre-anesthesia assessment (performed by provider) 
  • Continuous intraoperative monitoring documentation 
  • Medications, dosages, route, and timing 
  • Patient response and physiological status 
  • Post-anesthesia evaluation documentation 
• Ensures no required elements are omitted prior to case closure 

Clinical Record Standards (AAAHC Chapter 5)

• Maintains confidentiality and security of patient records in compliance with HIPAA 
• Ensures records are: 
  • Accessible 
  • Organized 
  • Completed within required timeframes 
• Assists with record audits and supports quality improvement activities 

Quality Improvement (QAPI) Participation

• Participates in ongoing monitoring of anesthesia documentation compliance 
• Assists in identifying trends such as: 
  • Missing documentation elements 
  • Late authentication 
  • Incomplete anesthesia records 
• Supports corrective actions and process improvements 

Massachusetts-Specific Compliance Requirements

• Adheres to 105 CMR 140.000 (Clinic Licensure) requirements for ambulatory surgery centers 
• Functions within limitations defined by: 
  • 244 CMR (Board of Registration in Nursing) 
  • 243 CMR (Board of Registration in Medicine) 
• Does not perform any duties restricted to licensed providers 
• Ensures all entries are: 
  • Attributed to the scribe 
  • Authenticated by the supervising anesthesia provider 
• Supports compliance with DPH and CMS requirements that only qualified providers: 
  • Perform anesthesia assessments 
  • Administer anesthesia 
  • Conduct post-anesthesia evaluations 

Workflow & Communication

• Assists anesthesia providers with EMR navigation and efficiency 
• Prepares documentation templates prior to cases 
• Tracks case progression and communicates delays 
• Coordinates with perioperative staff and clinic staff to support efficient workflow 

Scope Limitations

The Scribe:

• Does not perform patient care, assessments, or clinical decision-making 
• Does not independently interpret or enter clinical judgments 
• Documents only what is directed by the anesthesia provider 

Requirements

Education

• High School Diploma or equivalent required 
• Medical terminology or healthcare documentation training preferred 

Experience

• Healthcare experience preferred (ASC, hospital, or procedural setting) 
• EMR experience strongly preferred 
• Familiarity with anesthesia terminology highly desirable 

Core Competencies

• Attention to Detail 
• Efficiency and Workflow Support 
• Strong Communication Skills 
• Professionalism and Confidentiality 
• Adaptability in Fast-Paced Environment 
• Commitment to Continuous Improvement 

Physical & Cognitive Requirements

• Ability to remain in the operating room environment for extended periods 
• Continuous EMR/computer use/paper charting when necessary
• Ability to observe, process, and document information in real time 
• Strong concentration and multitasking ability 
• Must possess the physical, mental, and cognitive skills needed to complete essential tasks, including abilities such as learning, remembering, focusing, categorizing, and integrating information for comprehension, problem-solving, and timely decision-making and wield exceptional inter-personal communication skills with diverse populations.

Work Environment

• Ambulatory surgery center operating room, perioperative areas, and clinic areas. 

Additional Information

This job description is not intended to be an exhaustive list of all duties. Responsibilities may change based on operational needs.

We are committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of our clinical groups will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital/domestic partner status, parental status, sexual orientation, and gender identity and/or expression, other dimensions of diversity or common human decency. We value diversity in thought and culture and welcome highly skilled, capable, competent, collegial members to our team.