At the direction of a physician or advanced practice/licensed independent practitioner functioning as the CPH Hospitalist, functions as an unlicensed assistive professional to assist the Hospitalist through assisting in navigating the EMR, retrieving patient information, recording patient information into the EMR, and ensuring that Hospitalist orders are accurately documented and signed by the Hospitalist and timely received and implemented by the patient care team; meets, and operates within, all federal/state and CMS regulatory requirements as an unlicensed medical scribe, and meets all DNV accreditations standards for performance in this role.
1. Medical Documentation: Under the direct supervision of the Hospitalist, and at the directive of the Hospitalist, accompanies the Hospitalist into the patient examination area, transcribes into the EMR documentation of medical processes including, but not limited to: history and physical examination information as given by the patient and Hospitalist, any procedures performed by the Hospitalist, diagnostic and procedural activity performed by the Hospitalist, instructions and prescriptions for care team follow up, and discharge/follow up information for the patient and the care team. Ensures that all documentation entered into the EMR is noted as transcribed by the scribe, and that the Hospitalist provides an original or electronic signature on such documentation, as required by federal/state and CMS regulations and DNV certification. Ensures that all communication processes required to effect implementation of Hospitalist orders are effectively and timely communicated and documented for care team follow up.
2. Information Administration: Manage all medical and administrative information, including hard copy and electronic files and data, with attention to appropriate confidentiality of information access and retrieval; utilizes EMR systems for on-demand information retrieval, preparation of communications and reports, as requested by the Hospitalist.
3. Customer Service: Provides service excellence to internal and external customers through professionally responding to customer needs and concerns, anticipating and responding to customer requests, demonstrating indefatigable patience, responsiveness, understanding and compassion in meeting the needs of all customers.
4. Communication: Ensures essential communication is accurately, timely produced, verified and effectively communicated so that the handoff of information is accurately documented and acted upon.