Position Title: Medical Scribes
Location: Oklahoma City,OK; New Jersey; Fargo, ND; Clarksburg, WV; Tucson, AZ; Louisville, KY; Hampton, VA; San Antonio, TX; Augusta, ME; Helena, MT; Manchester, NH; and Temple, TX
Duties/Responsibilities include but not limited to the following:
- Scribes shall document all physician or other LIP (Licensed Independent Practitioner) patient appointment dialog in real time in the VA’s Computerized Patient Record System (CPRS) utilizing free text and/or designated templates making sure to use appropriate appointment and note titles. Documentation shall include, but may not be limited to:
- History of the patient’s current illness/medical condition
- Current list of patient’s medications
- Information relating to the physician’s or other LIP’s physical exam
- Procedures performed by the physician’s or other LIP
- Physician’s or other LIP’s assessment as s/he examines the patient
- Physician ’s or other LIP’s diagnoses
- Physician’s or other LIP’s continued care plan, orders, and follow-up instructions
- Medical Scribes shall introduce themselves to the patient as working with physician X or other LIP. The Scribe will utilize standard VA protocol to properly identify the patient prior to physician or other LIP treating patient.
- Ensures all verbal interactions and security of written, printed, and electronic files complies with HIPAA, HITECH, and PHI Privacy Laws
- As they accompany physicians or other LIPs in their day-to-day activities of seeing and treating patients, Medical Scribes shall use a VA computer/workstation, that may be a stationary workstation located in the exam room or a laptop computer with or without a rolling workstation on a mobile cart to document the patient’s visit in CPRS.
- Medical Scribes shall locate and retrieve any past medical history, lab results, imaging studies, EKGs and other pertinent reports or medical records for the physician or other LIP to review.
- All documentation created by Medical Scribes shall be accurate and detailed and appropriately entered in the VA’s Computerized Patient Record System (CPRS).
- All documentation shall comply with HIPAA, HITECH, and PHI privacy laws.
- In compliance with Joint Commission requirements, Medical Scribes shall enter information into the patient’s record as dictated by physician or other LIP. All documentation entered by the scribe shall be clearly identifiable and distinguishable from that of the physician or other LIP, i.e.: “Scribed for Dr. X by name of the scribe and title” with the date and time of the entry. NOTE: Scribes may enter orders or pending orders for physicians or other LIPs but shall abide by local policy.
- Per Joint Commission requirements, when the physician or other LIP concludes the patient visit, the physician or other LIP will review all documentation completed by the Medical Scribe, make any necessary changes, and date and sign the chart. The physician or other LIP is ultimately responsible for all documentation of the patient’s visit.
- All documentation, recording, and authentication must take place before the Medical Scribe and the physician or other LIP leave the patient care area.
- Medical Scribes shall maintain professional conduct and the highest standard of integrity during interactions with physicians and other LIPs, patients, patients’ families, and other healthcare professionals. Medical Scribes shall consistently communicate and treat others in a courteous, tactful and respectful manner.
- All Medical Scribes and other contractor personnel provided shall meet the VA Dress Code and Professional Appearance requirements.
- Medical Scribes shall participate in meetings and conferences related to patient care documentation and quality improvement as requested and deemed appropriate by the Patient Service Line Director or his/her
- In support of the VA Central Office’s Medical Scribe Pilot Program, the Contractor shall provide to the COR, for each of the medical specialties, quarterly QA productivity measures to help evaluate the effectiveness of the pilot.
- The Contractor shall provide, by the first of every month, a detailed schedule for each specialty area as to the scribes that are assigned and their scheduled hours for the month.
- The contractor shall provide to the CO a weekly report for each scribe that describes which physician or other LIP the scribe worked with, how many appointments were attended each work day, the mode of each appointment (telephone, in person, telehealth, or other), and whether any patient refused the use of a scribe during an appointment including how many refusals and the stated reason for each. These reports shall be provided by the third business day of the following week.
- A monthly QA report for accuracy of Medical Scribe documentation shall be provided by the contractor Program Manager to the COR addressing: quality, timeliness and accuracy of documentation.
- All Medical Scribes provided shall be physically capable of standing and walking from room to room for extended periods of time.
- Education: Completion of an accredited Medical Scribe Training Program or equivalent degree program. However, it is recognized by VHA that a range of other education, certifications, or job experience may qualify contractor applicants for employment in this pilot program.
- Experience/Knowledge/Skills: Contractor Medical Scribes shall 1) be experienced at applying medical terminology and a knowledge of human anatomy to real world situations in their assigned medical scribe specialty and 2) understand and anticipate the clinical workflow of physical exams, medical procedures, laboratory testing, imaging, and medical decision making. Medical Scribes shall be skilled at anticipating and accurately completing medical documentation requirements. Contractor Medical Scribes shall be capable of working independently in VHA medical centers while following the or other licensed independent practitioner and documenting patient visits in real-time with limited supervision or oversight.
- Certification: Specific Medical Scribe Certifications for contractor personnel shall not be required. However, successful completion of contractor’s medical scribe training program or affiliated program shall be required.
- Technical Proficiency: Contractor Medical Scribes shall be technically proficient in the skills necessary to fulfill the government’s requirements. Competencies required by the Medical Scribes include:
- Excellent knowledge and understanding of medical terminology and technical spelling
- Proficient documentation skills which reflect ability to write concisely, clearly and demonstrate proper grammar and spelling
- Ability to type a minimum of 55 words per minute with accuracy
- Knowledgeable in computer operation with excellent keyboard skills
- Working knowledge of human anatomy and physiology
- Capable of learning and mastering the use of the VA’s Computerized Patient Record System (CPRS) program
- Knowledgeable of: HIPAA Laws and compliance, Center for Medicare and Medicaid Services (CMS) guidelines, HITECH Act standards, Joint Commission Accountability Measures, other accreditation standards and Privacy Laws
- Familiar with CPT and ICD-10 codes
Work Hours: There are 12 applicable VA Health Care Systems, consisting of Emergency Departments (ED) and Specialty Care clinics involved in the Medical Scribes Pilot. The exact hours of operation may vary by site. The services covered by this task order shall be furnished by the contractor as defined in the work schedules below.
Medical Scribe Work Schedules/Tour of Duty: A required tour of duty per contractor employee shall be eight (8) hours per day, Monday through Friday, on-site and forty (40) hours per work week. Work shall commence no earlier than 0700 hours and end no later than 1800 hours each work day. Compressed work schedule of 4-10 hour days can be assigned based on need.
Click here to apply online