Job Description:DHR Health - US:TX:Edinburg - VariesSummary:POSITION SUMMARY:Under the direction of the Emergency Department Director/Supervisor and ER Physician Medical Director, the Clinical Documentation Specialist’s primary responsibility is to function as a Medical Assistant to support the ED physicians with clinical documentation requirements & coordination with registration, nursing, EMS, and ancillary departments to uphold the standards required for documentation of patients’ charts, including Stroke, Chest Pain, and Trauma Centers of Excellence & TJC Accreditation. Additionally, will accompany the physician as he/she examines and interviews patients, and simultaneously record the physician’s observations and comments on either HIPAA-compliant pre-draft document paper or directly into the electronic medical record (EMR). All information is recorded in the presence of a physician and is pertinent to Hospital/Facility documentation standards.POSITION EDUCATION/ QUALIFICATIONS:
High School graduate or equivalency.
Medical Terminology or Medical Assistance certification preferred.
Excellent customer service skills.
Computer skills required with knowledge of Microsoft Office suite.
Good written and verbal communication skills required.
Bilingual – English/Spanish.
JOB KNOWLEDGE/EXPERIENCE:
Experience in the Emergency Department or Acute Care Facility preferred.
Responsibilities:POSITION RESPONSIBILITES:
Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
· Gather data for physician review (i.e., Obtain pre-hospital EMS/Nursing homes/Other facilities external medical records, laboratory results, faxed radiology reports, and medical records)· Keep track of internal & external laboratory tests, medications, EKGs to scan into Cerner, and radiology tests ordered by the physician· Coordinate communication between ER physicians and: Ancillary Specialty Physicians; Primary Care Providers; inbound & outbound telephone calls; Nursing & Staff for ER patient throughput and flow· Document all consultations & interactions the ED physician makes to a patient’s primary care provider, specialty physician, family members, or on-call physician.· In the presence of the ER physician, document required Joint Commission Accreditation standards of required documentation for a patient’s chart.· Assist ER Staff with providing patients with updates about waits and delays (Non-clinical decision-making)· Document all procedures performed by the ED physician (Procedures may include life performing support, reducing dislocations, suturing, etc.)· Responsible for collaborating with the ER Physician to ensure the provider documents all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient.· Provide charts and information to the following departments (not limited to): Quality, Infection Control, HIM, Compliance, and any approved DHR entity in a HIPAA-Compliant format.· Other duties as assigned.Other information:LINES OF REPSONSIBILITES:(Chain-of-command)1. Clinical Documentation Specialist (Scribe) → 2. Emergency Department DirectorCUSTOMER 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· Standing/Squatting· Yes· Straight pulling· Yes· Sitting· Yes· Pulling hand over hand· Yes· Pushing· Yes· Repeated bending· Yes· Stooping/Bending· Yes· Reaching above shoulder· Yes· Climbing Stairs· Yes· Simple grasping· Yes· Climbing Ladders· No· Dual simultaneous grasping· Yes· Depth Perceptions needed· Yes· Ability to see· Yes· Identify Colors· Yes· Operating office equipment· Yes· Twisting· Yes· Operating mechanical equipment· Yes· Crawling· No· Ability to read and write· Yes· Ability to Count· Yes· Ability to hear verbal communication without aid· Yes· Operating Personal Vehicle· Yes· Ability to comprehend written/verbal communication· Yes· Other: Ability to deal with stress· Yes· OSHA Category· III··B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.D. Aptitudes: HIGH 1 2 3 4 5 6 LOWIntelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3Numerical: Ability to perform arithmetic operations quickly and accurately. 2Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.If applicable certification will be completed within time frame of hire/transfer date.Employee Signature: Date: Transfer/Hire Date Effective: .
