Documentation Support Associate - Spinecare Center

Overview

To assist SpineCare physicians with rise of patient volume, documentation requirements, and non-clinical physician responsibilities while offering a viable alternative to the current “care then document” model.  Trained and continuously assessed non-clinical assistant to the physician intended to maximize physician availability for direct patient care.

 

Responsibilities

 

Organization of objective healthcare data. Assisting the physician with note taking that is deemed pertinent by the physician to aid in the final production of the legal medical record.  Notes can include the physician’s verbalized interaction with patients, physical exam finding, medical decision making, medication orders, laboratory results, radiology reports, clinical re-evaluations, consultations, and dispositions.

Assist with reviewing of diagnosis and adding at the request of the physician or by MRI review.

Assist with generation of “PIN” numbers for patients through the GE Centricity product for the patient portal.

Assist with scanning of patient information from document management into GE Centricity.

Provides the physician with real time access to documentation without compromising normal routes of department communication. Ensures the appropriate medical legal documentation is completed in parallel with the actual clinical care.

Assists in obtaining old medical records and locating previous studies.

Assists with documentation of physician quality reporting, workers’ compensation documentation, and preparation of transfer notes.

Edit/review patient charges for office and procedure visits, if needed.

Miscellaneous tasks may include getting coffee or tea for family members, providing directions to visitors, and alerting a nurse when a patient expresses need for assistance.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Qualifications

Items Required:

 

High School diploma or GED.  Excellent time management and organizational skills.  Computer skills; Meditech experience preferred.  Prior experience in healthcare, classes in medical terminology or anatomy preferred. A typing test is required, with a minimum of 30 words per minute. Office Applications Certificate preferred

 

Must be able to read, write legibly, speak, and comprehend English.

 

Items Preferred:

 

Experience in a physician’s office environment. Basic clinical knowledge of pain medicine procedures.