Documentation Specialist

Documentation Specialist

DHR Health - US:TX:Edinburg - Varies

The primary role of a medical "Scribe" is to assist the physician with the complete documentation of patients' charts. Scribes accompany the physician as he/she examines and interviews patients and then record the physician's observations and comments on the electronic medical record (EMR). The scribe is not to enter orders into the medical record. All information is recorded in the presence of the physician. The role and signature of scribe, as well as timing of entries is required into the medical record electronic or manual. E.g. "Scribed for Dr. X by name of the scribe and title" with the date and time of the entry. The physician or practitioner must then authenticate the entry by signing, dating and timing it. The scribe cannot enter the date and time for the physician or practitioner. The authentication must take place before the physician or practitioner and scribe leave the patient care area. This position will be stationed in the Emergency Department at Starr County Memorial Hospital located at 128 FM 3167, Rio Grande City, Texas.

Position Education/Qualifications:

• High School graduate or equivalency.
• Associates degree preferred.
• Medical Terminology or Medical Assistance certification preferred.

Job Knowledge/Experience:

• One (1) year experience in a physician office setting and/or an acute care facility preferred.
• Excellent customer service skills.
• Computer skills required with knowledge of Microsoft Office suite.
• Previous experience with an EMR system preferred
• Good written and verbal communication skills required.
• Requires reasoning ability and good independent judgement
• Bilingual English/Spanish

Responsibilities:

Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices

Document any communication the Emergency Physician makes with a patient's personal doctor, family members, and other health care providers as outlined in position summary.

Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician's encounter with the patient and others present

List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.

Keep track of laboratory tests, medications, and radiology tests ordered by the physician

Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)

Coordinate communication between physicians and staff, make and answer telephone calls if required

Document any consultations the physician makes to a patient's personal doctor, family members, on-call physician, or other members of the community

Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient

Document all procedures done by the physician.

Other duties as assigned by physician.

Other information:

LINES OF RESPONSIBILITIES :

(Chain-of-command)

1. Physician, Manager 2. Chief Medical Information Officer

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC :

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA) :

A. Essential Duties : Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:

Light/moderate lifting up to 20 lbs, from the floor to shoulder height.

Kneeling

Must be able to assist other employees with lifting more than 20 lbs.

Walking

Light/moderate carrying up to 20 lbs.

Standing/Squatting

Straight pulling

Sitting

Pulling hand over hand

Pushing

Repeated bending

Stooping/Bending

Reaching above shoulder

Climbing Stairs

Simple grasping

Operating office equipment

Twisting

Operating mechanical equipment

Ability to read and write

Ability to hear verbal communication without aid

Operating Personal Vehicle

Ability to comprehend written/verbal communication

Other: Ability to deal with stress

OSHA Category - III

B. Working Conditions : The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes : HIGH 1 2 3 4 5 6 LOW

Intelligence: General learning ability: The ability to "catch on" or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to "visualize" objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.