Virtual Clinical Asst
2 months ago
The role of the scribe is to assist the physician with documentation of the patient's medical record.A scribe explains to the patient what the patient should expect from technician's work up and from the physician.Scribes completes a detailed patient history which includes past medical history (systemic and ocular), family medical history (systemic and ocular), medication history (systemic and ocular) and the chief complaint (the reason for the visit).
- The scribe, under the direction of the physician, transcribes the impression and plan, results of tests, prescriptions, and orders.
- The scribe documents any procedures that may be performed by the physician or ophthalmic medical personnel.
- The scribe transcribes any consultations or discussions with family members.
- The scribe does not directly assist with patient care.
- Attends required staff and educational meetings as requested.
- Maintains strictest confidentiality.
- Electronic Health Records
- History Taking
- Ophthalmic Abbreviations
- Ophthalmic Acronyms
- Ophthalmic Anatomy
- Ophthalmic Instruments
- Ophthalmic Patient Services
- Ophthalmic Pharmacology
- Ophthalmic Supplemental Skills
- Ophthalmic Terminology
- Accuracy
- Confidentiality
- Associates Degree minimum / Bachelor's Degree preferred
- Relevant: 2-3 year of Retina Scribe experience required
- Ophthalmic Assistant/Technician, with or without COA/COT: 1 year (preferred)
- Screening and technical workups to support provider visit requirements including patient histories, preliminary examinations, and testing in order to facilitate patient flow of 4-6 patients per hour. May include histories, refraction, topography, keratometry, tonometry, pupil testing, visual field testing, OCT, fluorescein angiography, biometry A-Scan/ IOLMaster, fundus and optic nerve photography as well as pachymetry as needed.
- Specialized and advanced testing support for provider visit requirements, prescribed practice patterns and other provider orders.
- EMR entry, notes, charting and assist as scribe for physician as required, as well as EMR documentation of all patient communications.
- Communication with patients regarding appointment scheduling, follow-up care, surgeries, procedures, changes in schedule, symptoms, surgery scheduling, additional testing and any other matters as directed by Lead Technician or provider.
- Presentation of informed consent documentation and pre- and post-operative instructions.
- Instrumentation set up and/or equipment for in-office minor surgery and laser procedures; assists with procedures, cleans exam/treatment rooms, and sterilizes instruments after use.
- Ophthalmic pre-exam workup, basic and advanced ophthalmic testing including but not limited to demonstrated proficiency in case histories, visual acuity testing, EOM, and pupil testing, keratometry, tonometry, visual field testing, OCT testing, topography, fundus, optic nerve and external photography, biometry A-Scan/IOLMaster, preliminary slit lamp exams with angle grading.
- Thorough knowledge of eye anatomy, disease, symptoms, surgical procedures, and ocular medications.
- Understands and utilizes sterile technique and procedures.
- Understands and follows procedures for surgical and procedural consents, pre- and post-operative instructions.
- Understanding and analytic capabilities consistent with operational flow analysis and coding and compliance.
- Knowledge of and facility with electronic medical record (EMR) and practice management (EPM) systems.
- Excellent interpersonal and organizational skills and demonstrate energetic professional, empathetic and maintain certification.
- Demonstrates ability to assist providers with 4-6 patient encounters per hour.
- Excellent interpersonal and organizational skills and demonstrate energetic professional, empathetic demeanor to patients and coworkers.
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