ICU Clinical Documentation Specialist- PT- Days/ Weekends

POSITION SUMMARY:

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 records 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.
• 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.

JOB KNOWLEDGE/EXPERIENCE:

• 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.

LINES OF REPSONSIBILITES: