Documentation Specialist, Valley Cardio Shared

Documentation Specialist, Valley Cardio Shared - 20732

Posted 2 days ago

Summary:

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

The Primary role of a Documentation Specialist is to assist the physician with the complete documentation of patients’ charts. Documentation Specialists accompany the physician as he/she examines and interviews patients and then records the physician’s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Documentation Specialist will accompany physician on hospital rounds and consultations if required.

All information is recorded in the presence of a physician, as dictated by the physician.

POSITION EDUCATION/

QUALIFICATIONS:

• High School graduate or equivalency is preferred.
• Medical Terminology required.
• CNA or Medical Assistant certification from an accredited school preferred.
• Computer skills required with knowledge of Microsoft Office suite.
• Good written and verbal communication skills required.
• Bilingual – English/Spanish.

JOB KNOWLEDGE/

EXPERIENCE:

• One (1) year experience in a hospital or physician office setting is preferred
• Previous experience as a medical scribe preferred
• Demonstrates proficiency in Microsoft Office applications
• Previous experience with an EMR system preferred
• Must have excellent customer service and organizational skills
• Requires reasoning ability and good independent judgment

Responsibilities:

POSITION 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
• 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
• Document any consultations the physician makes to a patient’s personal doctor, family members, on-call physician, or other members of the medical community
• Take vital signs and room patients as needed
• Accompany provider to hospital to document consults or hospital rounds as needed
• Provide patients with updates about waits and delays
• Document all procedures done by the physician, as dictated by the physician
• Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient
• Other duties as assigned

LINES OF RESPONSIBILITY:

(Chain-of-command)

Other information:

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.

Yes

Kneeling

Yes

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

Yes

Walking

Yes

Light/moderate carrying up to 20 lbs.

Yes

Yes

Straight pulling

Yes

Yes

Pulling hand over hand

Yes

Pushing

Yes

Repeated bending

Yes

Yes

Reachi…