Job Description
- Prepares and assembles medical record documentation/charts for physician(s).
- Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
- Ensures medical record compliance by self-documentation attestation.
- Updates patient history, physical exam, and other pertinent health information in the patient
- Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
- Monitors the duration of basic lab results and screening procedures.
- Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
- Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.