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OPHTHALMIC SCRIBE

Department: Clinical

Reports to: Practice Administrator

About the Position: The Ophthalmic Scribe will be responsible for accurately documenting patient encounters, medical histories, and examination findings directly into the Electronic Medical Records (EMR) system under the direction of the attending ophthalmologist/optometrist. The scribe will play a crucial role in ensuring efficient clinical flow and enhancing patient care by allowing the physician to focus on direct patient interaction.

Required Education and Experience: 

1. High school diploma or equivalent; further medical scribing or ophthalmology certification is preferred.
2. At least one year of experience in an ophthalmic setting.
3. Proficiency in English is required; bilingual is a plus.
4. Experience with ophthalmic diagnostic equipment such as OCT, topography, and fundus photography.
5. Knowledge of medical terminology, especially ophthalmic terms.
6. Training and understanding HIPAA requirements and the importance of maintaining patient confidentiality.

Essential Skills and Abilities:

1. Understanding of medical terminology, anatomy, and physiology used to document patient exams accurately. 
2. Ability to educate patients regarding installing eye drops and other instructions related to the physician’s treatment plan.
3. Familiarity with ophthalmic medical procedures, tests, and treatments.
4. Proficiency with EMR systems and strong computer skills.
5. Ability to accurately document patient encounters in a timely manner.
6. Excellent written, verbal, and interpersonal communication skills.
7. Ability to multi-task and prioritize tasks effectively in a fast-paced medical environment.
8. Strong organizational skills with attention to detail.
9. Being a team member and working collaboratively with other staff members.

Key Responsibilities:

1. Accompany the ophthalmologist/optometrist during patient examinations and procedures, ensuring a supportive role.
2. Summarize and document the physician's verbalizations during an examination, including examination charting, chief complaint additions, assessments, and treatment recommendations with justifications.
3. Assist the physician during exams as needed, such as holding the patient's head at the slit lamp, administering medications, providing instruments, and responding to medical emergencies.
4. Stay aware of the patient's verbal and nonverbal cues when the physician gives instructions, possibly repeating information, providing written instructions, or distributing patient education materials for home review.
5. Understand the examination components necessary for accurate CPT coding, ensuring all elements are completed and coded correctly.
6. Comprehend Medicare and other insurance standards for quality reporting to aid the practice in meeting payer requirements.
7. Remain near the physician throughout the clinic session to avoid missing documentation opportunities.
8. Prepare eyeglasses, contact lenses, or medication prescriptions for the physician's signature before completing the examination.
9. Complete the superbill or enter billing orders and the check-out form as directed by the physician, offering guidance to the patient before moving on to the next patient.
10. Perform diagnostic tests, including visual fields, OCT, Fundus photography, corneal topography, and other assigned tests.
11. Seeks advice from more senior staff as necessary, never performing medical care beyond capabilities.
12. Informs patients of the purpose of all tests personally performed and how they will be affected during the tests.
13. Participates in clinic meetings/activities; supports the clinical, departmental and organizational philosophy and goals

Physical Activity of Position:

• Talking. This position requires expressing or exchanging ideas utilizing the spoken word to convey detailed or essential verbal instructions to physicians, staff, and vendors accurately and succinctly.
• Hearing. This position requires the employee to perceive sounds at normal speaking levels with or without correction—the ability to receive detailed information through oral communication and discriminate in tone. Ability to hear softly spoken words.
• Repetitive motion. This position requires substantial movements (motions) of the wrists, hands, and fingers while working on reports or on the computer. Manual dexterity for typing, writing legibly, and handling medical equipment.
• Sedentary work. This position may require lifting objects weighing between 10 to 30 pounds. Assisting elderly patients with movement to and from exam chairs. Prolonged periods of standing and walking. Stooping, bending, and stretching during medical procedures or equipment management.
• Visual Requirements: This position requires good vision and observation skills for transcribing clinical findings.

Equal Opportunity Employer:

Colorado Ophthalmology Associates is an equal employment opportunity employer and complies with all applicable laws relating to discrimination against qualified applicants or employees in hiring or in any decision affecting job status, pay, or any other terms and conditions of employment based on race, color, creed, religion, national origin, sex, marital status, familial status, disability, genetic information, sexual orientation, age, or other applicable protected classes.