Ophthalmic Technician / Scribe

JOB DESCRIPTION

POSITION: Ophthalmic Scribe/Technician

DEPARTMENT: Clinical

REPORTS TO: Clinical Manager

JOB SUMMARY: This individual is responsible for providing accurate documentation and summarization of the ocular examination and recommendations while maintaining patient flow and communication regarding appointment status.

EDUCATION AND EXPERIENCE:

1. High school diploma.

2. Minimum of one year experience in a medical office, preferred, but not required.

3. Excellent spelling ability.

ESSENTIAL SKILLS AND ABILITIES:

1. Training and understanding of HIPAA requirements and the importance of maintaining patient confidentiality.

2. Strong, professional interpersonal skills.

3. Demonstrated respect for staff and patients.

4. Excellent verbal and written communication.

5. Team-orientation.

6. Management of multiple projects simultaneously.

7. Strong organization with attention to detail.

8. Computer literacy.

9. Ability to educate patients regard instillation of eye drops and other instructions related to physician’s treatment plan.

RESPONSIBILITIES:

1. Correctly summarizes and documents what the physician verbalizes during an examination, including but not limited to: proper charting of the examination, documenting additions to the chief complaint, assessment and recommendations for treatment (including justification of decisions reached when appropriate).

2. Knows required components of examination for appropriate CPT coding to ensure all elements are accurately completed.

3. Understands Medicare and other common insurance requirements for quality reporting in order to help practice comply with payer requirements.

4. Observes the patient and the physician and assists when appropriate during the exam, including but not limited to: holding the patient’s head in the slit lamp, providing additional medications and/or instruments, following directions in a medical emergency.

5. Maintains an awareness of the patient’s verbal and non-verbal communication when the physician is providing instructions as it may be necessary for the scribe to repeat information, provide written instructions, and/or hand out patient education materials for the patient to review at home.

6. Ensures patient understands all instructions.

7. Accurately documents chart errors according to practice protocols.

8. Helps maintain the patient flow by seating patients into empty exam room to prep for physician.

9. Remains as close to the physician as possible during the assigned clinic session, and limits time away from the physician and the patient as documentation may be missed.

10. When applicable, prepares accurate eyeglass or contact lens prescriptions and/or medication prescriptions for the physician’s signature prior to the completion of the examination.

11. Alerts physician to patient-related forms that need completion.

12. When appropriate, and as directed by the physician, completes the superbill or enters billing orders, and/or the check-out form, providing direction to the patient prior to following the physician to the next patient.

13. Ensures proper follow-up appointments are communicated to the front desk to be made before the patient leaves.

14. Learns the personality and preferences of each physician, recognizing differences and abiding by them when working with that particular physician.

15. Becomes fluent in the exact requirements of each examination.

16. Accommodates the needs of the patient for the exam:

a. Monitors examination room and any physical limitations the patient may have.

b. Makes sure the patient chair is down before the patient prepares to leave, the equipment is off, the slit lamp is out of the way, equipment is sanitized, etc.

c. Provides patient with their cane, handbag, coat, etc. to expedite patient flow when exiting the exam room.

d. Evaluates the condition of the examination room to ensure adequate supplies are in stock.

e. Notifies physician of changes to the daily schedule, especially emergencies.

f. Facilitates communication between the physician and other staff members as helpful to minimize clinic flow disruptions.

g. Performs other tasks as required.

1. Communication and Patient Care

a. Acquaints all new patients with office procedures to which they will be exposed.

b. Informs patients of the purpose of all tests personally performed, and how the patient will be affected during the tests.

c. Obtains patient history to include chief complaint, history of present illness, past history (ocular and general), family history (ocular and general), and history of allergies and medications.

d. Performs accurate and consistent documentation and measurement tasks to include:

· Visual acuity

· Confrontational visual fields

· Stereo testing

· Evaluation of motility

· Pupillary function tests

· Color plates

· Applanation tonometry

· Angle assessment

· Dilation of pupils

· Visual field testing

· Optic nerve scanning (i.e. OCT, HRT, GDx)

· Pachymetry

· Corneal topography

· Other tasks specific to the physician’s needs as a result of new technologies

e. Provides back-up to the ophthalmic photographer regarding fundus, exterior and anterior segment photographs.

f. Assists physician with laser procedures.

g. Assists physician with minor surgery, maintaining practice standards of sterile technique and infection control.

2. Triage

a. Determines which patient should be taken next from the waiting room to have testing initiated.

b. Escorts all patients from the waiting room for data collection.

c. Advises patients as to who will see them following testing and makes patients comfortable during wait.

d. Maintains a smooth flow of patients to the physician, altering the test sequence as required.

e. Provides telephone support regarding ocular emergencies, prescription refills, and patient care questions.

f. Communicates with reception to facilitate proper patient flow.

3. Instrument Maintenance

a. Troubleshoots instruments as necessary.

b. Replaces bulbs.

c. Checks connections.

d. Performs archiving functions according to manufacturer recommendations.

e. Performs autoclaving and maintenance of instrument sterility.

f. Reports continued difficulty to Clinic Manager.

4. Administrative

a. Seeks advice from more senior staff as necessary, never performing beyond capabilities.

b. Maintains cleanliness in exam and procedure rooms.

c. Maintains back up levels of stock in exam and procedure rooms.

d. Performs other duties as required

PHYSICAL ABILIITES:

1. Must be able to walk and stand for entire work shift.

2. Must be able to move frequently from standing and sitting depending on exam room configuration during clinic sessions.

3. Must be able to type or write legibly in a dimly-lit setting.

4. Must be able to hear softly spoken words.

5. Must be able to add support for elderly patients getting in and out of exam chairs.

6. Lifting required up to 30 pounds.

4. Perform other duties as required.

Job Type: Full-time

Work Location: In person