Description

Full-Time, Days
DHR Health

POSITION SUMMARY: The Primary role of a Clinical Documentation Specialist is to assist the  physician with the complete documentation of patients’ charts. Transcribes 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 hospital uses. All information is recorded in the presence of a physician

POSITION EDUCATION/QUALIFICATIONS: •High School graduate or equivalency. •Medical Terminology or Medical Assistance certification preferred. •Two (2) years experience in an MD office preferred. •Excellent customer service skills. •Computer skills required with knowledge of Microsoft Office suite. •Good written and verbal communication skills required. •Bilingual – English/Spanish.

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 ED physician makes to a patient’s personal doctor, family members, or on-call physician. •Provide patients with updates about waits and delays •Document all procedures done by the physician. Procedures may include life performing support, reducing dislocations, suturing, etc. •Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient. •Other duties as assigned.