Job Description
Position Status:
Full time
Shift:
First Shift (Days - Less than 12 hours per shift) (United States of America)
Hours per week:
40A Brief Overview
This position spends a high percentage of time performing medical transcription duties as a "real time" Documentation Assistant for a specific physician. Time is spent routing and processing documentation and delivering reports to physicians for review in a timely manner. Core responsibility is to capture accurate and detailed documentation of the patient encounter in a real time manner. Member uses acquired, office-based skills to assist physicians and nursing personnel to maintain smooth working order of the offices, continuity of patient care and client satisfaction.
Essential Job Duties
- Implements identified plan through coordination of care with interdisciplinary care team to employ strategies to promote health and wellness. Collaborative with interdisciplinary care team encompassing strategies to achieve expected outcomes.
- Communicate pertinent data and information relative to the patient, situation, or setting in a timely manner. Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.
- Promote infection prevention through use of standard precautions, proper procedure in dressing changes, wound care, hand hygiene and cleanliness of the patient rooms/department.
- Provide assistance with activities of daily living (ADL'S), accurate measurement and recording of weight, height, vital signs and report any changes to assigned nurse.
- All documentation assistant entries must contain an entry made by the provider that: Affirms the providers presence during the time the encounter was recorded, verifies provider reviewed the information, verifies of the accuracy of the information with provider authentication including date and time.
- Assist the provider in navigating the EHR. Respond to various EHR messages as directed by the provider. Enter information into the EHR as directed by the provider. Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response. Ensure that all entries in the EHR by the Documentation Assistant are authenticated by the Documentation Assistant including date and time.
- Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
- Performs other duties as assigned
Qualifications
- At least one completed semester in a nursing or medical education program. Required or
- Active Certified Nurse Assistant (CNA), OR completed a Medical Assistant program, OR Emergency Medical Technician (EMT). Required
- 1 year Transcription/scribe/MA or PCT experience Preferred
- Experience typing or transcribing conversations. Required
- Experience in a medical setting working with providers. Required
- Experience with medical terminology and procedures. Required
- Active Certified Nurse Assistant (CNA) OR Emergency Medical Technician (EMT) certification is required unless MA or nursing education requirement is met.
Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.
Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.
Job Tags
Full time, Work at office, Shift work, Day shift,