Scribe

Position Summary/Scope of Responsibility

The Centers for Advanced Orthopaedics LLC (CAO) is one of the nation’s largest Orthopaedics practices, owned and operated by physicians, with over 60 locations across Maryland, Northern Virginia, and the District of Columbia. With approximately 2,000 employees, working in 28 Divisions, CAO is a growing business with revenues of approximately $250 Million. CAO is committed to be the Orthopaedics provider of choice for our patients; partner of choice for payors and health systems; and employer of choice by attracting and retaining a talented workforce.

The Scribe prepares and assembles medical record documents/charts for physicians and prepares and sends all documentation to physicians for review and approval. The Scribe ensures medical record compliance and complies with hospital and medical facility policies. Responsible for updating patient history, physical exams, and other pertinent health information and monitoring the duration of basic lab results and screening procedures.

Duties: include, but are not limited to:

• 1.
• Prepares and assembles medical record documentation/charts for physician(s).
• 2.
• Accompanies physician(s) during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
• 3.
• Ensures medical record compliance by self-documentation attestation.
• 4.
• Updates patient history, physical exam, and other pertinent health information.
• 5.
• Prepares and sends all documentation to physician(s) for review and approval via authentication of detailed data entry and facility-specific procedures.
• 6.
• Monitors and documents the duration of basic lab results, radiographic studies, and screening procedures as dictated by the physician(s).
• 7.
• Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
• 8.
• Refers all requests related to patient care to the responsible physician or nursing staff.
• 9.
• Performs other duties as assigned.

• Required Education & Experience
• High School Diploma or Equivalent.
• Skilled in operating various medical record software and hardware, word-processing, and database software programs.
• Knowledge of medical terminology and human anatomy preferred.