Job Description

POSITION SUMMARY :

The Physician Documentation Assistant/Scribe accompanies providers in the Emergency Department and documents during patient visits, and ensures medical records are complete and

ready for provider review.

Position: Physician Documentation Assistant        

Schedule: Part Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Accompanies the physician into the exam room and documents the patient’s history, physical examination, and vital signs. Obtains critical laboratory results to the physician, to prioritize the physician’s time.

• Performs accurate, real-time charting of patient encounters. Adheres to all required guidelines for proper documentation to allow for accurate reporting and billing.  This includes detailed recording of the elicited history, physical examination, diagnostic testing results, and appropriate and comprehensive summarization of the ensuing discussion and plan developed by the patient and provider.

• Ensures that all required test orders, prescriptions, and other required referrals are placed in the medical record during and immediately following the encounter, ready for the provider to sign.

• Ensures that copies of the encounter documentation are presented to the patient, to their primary care provider, and to all other care providers for the patient.

• Ensures that all documentation is grammatically correct with correct spelling; as copies of the notes are provided to the patient, thorough editing of the record ensures adherence to high quality standards and ensures accurate communication with other providers.

• Perform other related duties as assigned.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• High school diploma or equivalent required.

• Preferred: Currently enrolled in a BA/BS or Master's program for the next 12+ months

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• None

EXPERIENCE:

• No prior experience required

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.

• Strong written and verbal communication skills.

• Ability to actively listen.

• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English.

• Ability to spell proofread and edit written text.

• Keyboard proficiency (approximately 70 words/minute).

• Ability to operate a personal computer and related software applications.

• Strong attention to detail.

• Ability to work in a dynamic, highly-stress environment that routinely involves exposure to highly-sensitive personal medical issues.

• Ability to coordinate multiple projects and patients.

• Ability to problem solve under pressure.

• Ability to communicate and interact professionally with others.

• Understanding of and commitment to appropriate protection of confidential patient information.

• Commitment to high professional ethical standards.

Equal Opportunity Employer/Disabled/Veterans

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