Scribe/Ophthalmic Writer, UPMC

The Full-time Scribe / Ophthalmic Writer supporting the UPMC Vision Institute at 1622 Locust Street, Pittsburgh, PA 15219 plays a key role in documenting high‑quality clinical care. This position works daylight hours, Monday-Friday between 7:00 AM and 5:30 PM, with shift start times varying based on clinic schedules. The writer accurately captures and documents all physician findings during examinations, including proper charting, updates to the chief complaint, assessments, and treatment recommendations—providing justification when appropriate. This role requires close attention to patient communication; the writer must remain aware of both verbal and non‑verbal cues to determine when instructions need to be repeated, clarified, or supplemented with written materials or patient‑education resources. Ensuring that each patient fully understands their instructions is a core responsibility of this position.

Responsibilities:

Alerts eye physician to patient-related forms that need completion. When appropriate, completes the superbill and/or the check-out form, providing direction to the patient prior to following the physician. Maintains an awareness of the patient's verbal and non-verbal communication when the physician is providing instructions as it may necessitate the writer repeating information, providing written instructions, and/or patient education materials for the patient to review at home. Learns the personality and preferences of each physician, recognizing differences and abiding by them when working with that particular physician. Ensures patient understands all instructions. Correctly summarizes and documents what the physician says 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). Maintains patient flow, by ensuring a minimum of two patient rooms are always occupied. Accommodates the needs of the patient for the exam:

Monitors examination room and any physical limitations the patient may have. 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, etc. Provides patient with cane, handbag, coat, etc. to expedite patient flow.

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

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

Performs other tasks as required. Guides patient to front desk after completion of exam and ensures proper follow-up appointments are made. Accurately documents chart errors according to the following format:

One line is to be drawn through the mistake.

The initials of the person making the error are to be written. The corrected information can then be documented. Remains as close to the physician as possible and limits time away from the physician and the patient. Becomes fluent in the exact requirements of each examination. When applicable, prepares accurate eye glass or contact lens prescriptions and/or medication prescriptions for the eye physician's signature prior to the completion of the examination.