Clinical Document Specialist Scribe, Plastic & Recon Surg

Document Specialist, Plastic & Recon Surg - 21528

Posted yesterday

DHR Health - US:

TX:

Edinburg -

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

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.

The Primary role of a medical “clinical documentation specialist” is to assist the physician with the complete documentation of patients’ charts. Clinical documentation specialist 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. Clinical 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.

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

• 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

• 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

• Practice Manager
• Director DHR Health Clinics
• Chief Ambulatory Officer

(Chain-of-command)

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.

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.

A. Essential Duties:
Indicated by bold print within performance…