Data Transcriber - Medical Scribe

Department of Veterans Affairs

This position is located at the Robley Rex VA Medical Center in Louisville, KY. This position will serve as a member of a diverse, multi-professional team who works at the direction of a licensed independent practitioner (LIP) to capture and enter information into the Electronic Health Record (EHR).

• ***THIS IS NOT A VIRTUAL POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION*** MAJOR DUTIES: Accompanies Licensed Independent Practitioners (LIPs) during each patient visit and documents/transcribes information in the Electronic Health Record (EHR) that transpires during the LIP's visit at the direction of the LIP. Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician. Prepares operative reports, makes phone calls, and conducts other clerical tasks as assigned. Enters all aspects of the patient encounter into the EHR including the patient history, physical exam findings verbalized by the LIP, procedures, orders, and clinic encounters. Facilitates efficient patient flow through the clinic by ensuring timely processing of orders, including referrals, tests, medications, and encounters, and by preparing and forwarding documentation to the LIP for review, approval, and signature. Documents all aspects of the office visit (handwritten, electronic, or otherwise) in the EHR during the patient encounter with the LIP. Organizes information consisting of, but not limited to, plan and patient instructions in the EHR, assists the LIP in navigating the EHR, and locates information for review (i.e. previous notes, reports, test results and laboratory results). Records diagnostic results such as radiology interpretations and lab values, and enters medication orders, physical therapy orders, home exercises, educational handouts, work restrictions and other orders per LIP instruction. Ensures accuracy, spelling, punctuation and grammar in documentation prior to LIP review and approval. Ensures records are prepared for treatment team review by providing previously ordered tests if appropriate, adequate forms for documentation by team, recent information profile for LIP to review and appropriate encounter form attached to the medical record, assembling medical information in correct sequential and chronological order. Ensures appropriate forms are completed, accurate and signatures obtained for requests/release of medical information. Initiates action to request records from other facilities, both VA and non-VA, and obtains all medical records as requested by treatment team. Assists treatment team in ensuring medical documentation complies with Joint Commission and other accreditation body requirements. Performs statistical data collection. Performs other related duties as assigned. Work Schedule: Intermittent - 7:00 a.m. to 3:30 p.m., or 7:30 a.m. to 4:00 p.m., or 8:00 a.m. to 4:30 p.m. NOTE: Intermittent employment is defined as non-fulltime employment in which employees serve under an excepted or competitive service appointment without a regularly scheduled tour of duty. A position with an intermittent work schedule is sporadic and unpredictable so that a tour of duty cannot be regularly scheduled in advance. Intermittent positions offer health insurance only if the employee is expected to work at least 130 hours per month for at least 90 days. Recruitment & Relocation Incentives: Not authorized Critical Skills Incentive (CSI): Not approved

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