POSITION SUMMARY :

The Primary role of a Clinical Documentation Specialist is to assist the physician with the complete documentation of patients’ charts. Clinical Documentation Specialists accompany the physician as he/she examines and interviews patients and then records the physician’s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Clinical Documentation Specialist will accompany physician on hospital rounds and consultations if required. All information is recorded in the presence of a physician, as dictated by the physician.

POSITION EDUCATION/QUALIFICATIONS :

• High School graduate or equivalency is preferred.
• Medical Terminology required.
• CNA or Medical Assistant certification from an accredited school 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 :

• One (1) year experience in a hospital or physician office setting is preferred
• Previous experience as a medical scribe preferred
• Demonstrates proficiency in Microsoft Office applications
• Previous experience with an EMR system preferred
• Must have excellent customer service and organizational skills
• Requires reasoning ability and good independent judgment
  Responsibilities:

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 2 0 lbs.
Yes
Walking
Yes
Light/moderate carrying up to 2 0 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

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: Category III
D. Aptitudes : HIGH 1 2 3 4 5 6 LOW
Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3
Verbal: 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. 3
Numerical: Ability to perform arithmetic operations quickly and accurately. 2
Spatial: 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. 2
Form 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. 3
Clerical 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. 2
Motor 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. 3
Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3
Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3
Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3
Color 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. 3
I 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: _______.

• Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
• Keep track of laboratory tests, medications, and radiology tests ordered by the physician
• Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)
• Coordinate communication between physicians and staff, make and answer telephone calls
• Document any consultations the physician makes to a patient’s personal doctor, family members, on-call physician, or other members of the medical community
• Take vital signs and room patients as needed
• Accompany provider to hospital to document consults or hospital rounds as needed
• Provide patients with updates about waits and delays
• Document all procedures done by the physician, as dictated by the physician
• Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient
• Other duties as assigned