About The Position

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 uses acquired, office-based skills to assist physicians and nursing personnel to maintain smooth working order of the offices, continuity of patient care and client satisfaction.

Requirements

  • Successfully completed first semester in an accredited nursing program. Required
  • Successfully completed a medical assistant or patient care technician program. Required
  • 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
  • 1 year Transcription/scribe/MA or PCT experience Required
  • Experience typing or transcribing conversations. Required
  • Experience in a medical setting working with providers. Required
  • Experience with medical terminology and procedures. Required
  • Conscientious regarding care of equipment, utilization of supplies and personal time. (Required proficiency)
  • Knowledgeable of correct set-up and procedures to safely perform ear irrigation, monitor oxygen via mask and nasal cannula, assist with suture care and removal. (Required proficiency)
  • Knowledgeable of and follows correct techniques in the ordering, collection, and labeling specimens; in assisting providers in clean or sterile procedures. (Required proficiency)
  • Possess the ability to organize and prioritize assigned work duties and have a desire to interact with patients in a professional and empathetic manner. (Required proficiency)
  • 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

Nice To Haves

  • Transcription/scribe/MA or PCT experience Preferred

Responsibilities

  • Implements identified plan through coordination of care with interdisciplinary care team to employ strategies to promote health and wellness.
  • Collaborative with interdisciplinary care team encompassing strategies to achieve expected outcomes.
  • Communicate pertinent data and information relative to the patient, situation, or setting in a timely manner.
  • Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.
  • Promote infection prevention through use of standard precautions, proper procedure in dressing changes, wound care, hand hygiene and cleanliness of the patient rooms/department.
  • Provide assistance with activities of daily living (ADL’S), accurate measurement and recording of weight, height, vital signs and report any changes to assigned nurse.
  • All documentation assistant entries must contain an entry made by the provider that: Affirms the providers presence during the time the encounter was recorded, verifies provider reviewed the information, verifies of the accuracy of the information with provider authentication including date and time.
  • Assist the provider in navigating the EHR.
  • Respond to various EHR messages as directed by the provider.
  • Enter information into the EHR as directed by the provider.
  • Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.
  • Ensure that all entries in the EHR by the Documentation Assistant are authenticated by the Documentation Assistant including date and time.
  • Delivers care guided by Jean Watson’s Theory of Human Caring illustrated by creating caring relationships, taking time to have uninterrupted moments with patients and displaying unconditional acceptance and respect.
  • 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.
  • Mentors PCT’s s new to their role for the purpose of ensuring successful enculturation, orientation, competence, and emotional support.
  • Supports students to enhance their knowledge, skills, and abilities.
  • 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
  • Utilizes appropriate resources to provide, and sustain evidence-based nursing services that are safe, effective, and financially responsible, and used judiciously
  • Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
  • Performs other duties as assigned
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