Job Description
Medical Transcription Documentation Assistant
Provides high quality documentation of the medical record through supervision by nursing and physicians. This position spends a high percentage of time performing medical transcription duties as a "real time" Documentation Assistant for a specific physician. Time is spent routing and processing documentation and delivering reports to physicians for review in a timely manner. Core responsibility is to capture accurate and detailed documentation of the patient encounter in a real time manner. Member of the patient care team who uses acquired, clerical skills to assist in maintaining efficient workflow to ensure safe, quality care with a patient centered approach focusing on continuity of patient care and satisfaction. This role is designed to support the Physician through the management and completion of the admission, progress notes and discharge summary within the scope of their practice. Making independent clinical decisions is outside of the scope for this position, refer clinical questions to the provider or nurse.
Education Qualifications:
- Successfully completed first semester in an accredited nursing program. Required or
- Successfully completed a medical assistant or patient care technician program. Required or
- A Certified Clinical Medical Assistant, Certified Medical Assistant, Registered Medical Assistant, Certified Nursing Assistant, or Emergency Medical Technician may be substituted for the educational requirement. Required
Experience Qualifications:
- 1 year Transcription/scribe/MA or PCT experience Preferred
- Experience typing or transcribing conversations. Required
- Experience in a medical setting working with providers. Required
- Experience with medical terminology and procedures. Required
Licenses and Certifications:
- Active certification to practice in Kansas as either Certified Clinical Medical Assistant, Certified Medical Assistant, Registered Medical Assistant, Certified Nursing Assistant, or Emergency Medical Technician is required as a substitute for education qualifications. Required
What You Will Do:
- Enters information in EHR as directed by provider. Respond to various EHR messages as directed by the provider. Ensure that all orders entered are read back and confirmed to provider and entered as Pended. Assist the provider in navigating the EHR
- Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.
- Efficiently documents information using the appropriate forms and/or electronic applications
- Responsible for the documentation of the patient's progress notes, and discharge summary under the direction and supervision of the physician. Documents in patient and department records in a timely, accurate and concise manner according to department standards.
- Evaluates the patient's progress towards achieving outcomes and provides information to the physician as requested.
- All documentation assistant entries must contain an entry made by the provider that: Affirms the providers presence during the time the encounter was recorded Verification that provider reviewed the information Verification of the accuracy of the information Provider authentication including date and time Individual is required to review and agree to abide by the Scribe/Team Documentation Assistant Policy.
- Promotes a mutually respectful environment that encourages the exchange of ideas and supports the effectiveness of professional relationships and integrates ethics in all aspects of practice.
- Demonstrates advocacy in all roles and settings.
- Practices Diversity, Equity and Inclusion principles in their daily work by respecting others' uniqueness, perspectives, backgrounds or beliefs.
- Communicates effectively in all areas of professional practice
- Understands the roles of the multidisciplinary team and is able to articulate their purpose and function within the department
- Demonstrates competence in documenting according to hospital policies, regulatory agencies, and accreditation standards.
- Coordinates care with consulting physicians.
- Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and development.
- Demonstrates willingness to participate in process of evolution the scope of the Stormont Vail Health professional practice model
- Leads therapeutic groups activities as assigned.
Required for All Jobs:
- Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
- Performs other duties as assigned
Patient Facing Options:
- Position is Patient Facing
Remote Work Guidelines:
- Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.
- Stable access to electricity and a minimum of 25mb upload and internet speed.
- Dedicate full attention to the job duties and communication with others during working hours.
- Adhere to break and attendance schedules agreed upon with supervisor.
- Abide by Stormont Vail's Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.
Remote Work Capability:
Scope:
- No Supervisory Responsibility
- No Budget Responsibility
Physical Demands:
- Balancing: Occasionally 1-3 Hours
- Carrying: Occasionally 1-3 Hours
- Climbing (Ladders): Rarely less than 1 hour
- Climbing (Stairs): Rarely less than 1 hour
- Crawling: Rarely less than 1 hour
- Crouching: Rarely less than 1 hour
- Driving (Automatic): Rarely less than 1 hour
- Driving (Standard): Rarely less than 1 hour
- Eye/Hand/Foot Coordination: Frequently 3-5 Hours
- Feeling: Occasionally 1-3 Hours
- Grasping (Fine Motor): Occasionally 1-3 Hours
- Grasping (Gross Hand): Occasionally 1-3 Hours
- Handling: Occasionally 1-3 Hours
- Hearing: Frequently 3-5 Hours
- Kneeling: Rarely less than 1 hour
- Lifting: Rarely less than 1 hour up to 25 lbs
- Operate Foot Controls: Rarely less than 1 hour
- Pulling: Occasionally 1-3 Hours up to 25 lbs
- Pushing: Occasionally 1-3 Hours up to 25 lbs
- Reaching (Forward): Occasionally 1-3 Hours up to 25 lbs
- Reaching (Overhead): Occasionally 1-3 Hours up to 25 lbs
- Repetitive Motions: Occasionally 1-3 Hours
- Sitting: Frequently 3-5 Hours
- Standing: Frequently 3-5 Hours
- Stooping: Rarely less than 1 hour
- Talking: Frequently 3-5 Hours
- Walking: Occasionally 1-3 Hours
Working Conditions:
- Burn: Rarely less than 1 hour
- Chemical: Rarely less than 1 hour
- Combative Patients: Frequently 3-5 Hours
- Dusts: Rarely less than 1 hour
- Electrical: Rarely less than 1 hour
- Explosive: Rarely less than 1 hour
- Extreme Temperatures: Rarely less than 1 hour
- Infectious Diseases: Occasionally 1-3 Hours
- Mechanical: Rarely less than 1 hour
- Needle Stick: Rarely less than 1 hour
- Noise/Sounds: Rarely less than 1 hour
- Other Atmospheric Conditions: Rarely less than 1 hour
- Poor Ventilation, Fumes and/or Gases: Rarely less than 1 hour
- Radiant Energy: Rarely less than 1 hour
- Risk of Exposure to Blood and Body Fluids: Rarely less than 1 hour
- Risk of Exposure to Hazardous Drugs: Rarely less than 1 hour
- Hazards (other
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