- Accompanying the clinical provider during patient examinations to transcribe clinician examinations/evaluations, medications, diagnosis(s), and treatment team discussions into the Electronic Medical Record and clinician progress notes in real time as needed by the Physician
- Contacting outside Providers to obtain collateral information to use in treatment and discharge planning, scheduling aftercare appointments as needed, in addition to notifying schools about patients' hospital admissions
- Assists facilitating phone calls between those involved in treatment and with insurance companies for reviews and grievances
- Have a knowledge-base of DSM and its usage
- General knowledge of substance abuse issues
- Knowledge of age specific populations
- Ability to address cultural diversity and specific patient/family issues
- Maintains competence in identified universal core and critical competencies
- Attends treatment team meetings to capture patient information
- Actively assists attending physician in the scribing of patient notes
- Displays excellence in customer service skills, returning all phone calls from internal staff members and external customers (i.e. medical advocate, schools, referral sources, etc.) within 24 hours
- Assists the Provider in navigating the Electronic Health Record (EHR)/Chart Serve as a point of contact and coordinate phone calls between physician and families, insurance companies and other providers in addition to checking messages for clinician throughout the day
- Locates information for review (i.e., previous notes, reports, test results, and laboratory results); Enter information into the chart/EHR as directed by the Provider
- Researches information as requested by the Provider. Actively assists attending physician in the scribing of patient notes
- Accompany clinical provider during patient examinations/evaluations to transcribe examinations/evaluations and other orders to the Electronic Medical Record in real time as needed by the Physician
- Records diagnoses and assist in preparing discharge and/or follow-up instructions as dictated by the clinical provider
- Verifies the chart as needed for an appropriate coding level to ensure it has been documented correctly for the designated ICD-9 and CPT code
- Checking messages for Physicians throughout the day
- 2-4 years of undergraduate education with emphasis in behavioral health or pre-medical studies.
- 2 years of experience working in a behavioral health environment preferred.
- Must have a passion for medicine, psychology, or social work and a desire to assist patients with Behavioral Health concerns.
- Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.
- Strong written and verbal communication skills.
- Ability to actively listen.
- Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
- Ability to spell proofread and edit written text.
- Keyboard proficiency
- Ability to operate a personal computer and related software applications.
- Strong attention to detail.
- Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal behavioral health/medical issues.
- Ability to be adaptable and be willing to take constructive criticism.
- Ability to coordinate multiple projects and patients.
- Ability to prioritize.
- Ability to problem solve under pressure.
- Ability to communicate and interact professionally with others.
- Understanding of and commitment to appropriate protection of confidential patient information.
- Commitment to high professional ethical standards.
- Compliance with Departmental and Hospital Health and Safety policies and procedures.
- 40 hour work week, hours and days to be determined by the business needs of the department. Additional hours may be required.
- Fast-paced hospital emergency department, inpatient unit, and outpatient clinic. Physical requirements include but are not limited to continuous standing during shift, repeated sitting, listening, fluorescent lighting, repetitive typing and key entry work, computer work, and other normal hospital and outpatient clinic conditions.
- Ability to push and maneuver a portable computer on wheels.
- The position may require some lifting up to 20 pounds. Interacts with patients, families, ancillary staff, nurses, social workers, physician assistants, physicians, and others.
- This job description is intended to describe the general nature and level of work being performed by people assigned to this position. It is not intended to be an exhaustive list of all responsibilities, activities and skills required of the position and people in the position.
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Behavioral Health Scribe - Detroit, United States - Wayne Health
Description
About Us:Serving one million patients and their families annually. Advancing medical knowledge, technologies and practices. Developing and educating the next generation of exceptional health care professionals.
With more than 100 locations in hospital-based clinics, outpatient health and specialty care centers, we provide the most advanced medicine and thoughtful, patient-centric care to the greater metro-Detroit community.
Job Summary:
Responsible for accurately documenting the patient-provider encounter. This is an in-person scribe position in an inpatient (hospital) setting, and in-person or virtual outpatient setting. Inpatient setting: The Behavioral Health Scribe rounds with a Psychiatric MD and mid-level Providers and documents the encounter in the hospital based EMR system or paper chart. Outpatient Setting: Works to facilitate patient flow and ensure an accurate and complete medical record for each patient as directed by the Provider/Physician.
Job Description:
Essential Duties and Responsibilities:
