Job Description
Position Summary:
Trained in structured clinical assessments, professional documentation, and team-based care in an ambulatory setting to prepare and assemble medical record documentation for providers in order to facilitate efficient and effective medical care between patients and clinical team members.
Orlando Health Physician Associates is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts and beyond. Collectively, our 27,000+ team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve.
Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions. “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.
Scribe Experience highly preferred.
Responsibilities:
Gathers data through patient or caregiver interviews and direct or indirect observation of clinical team member.
Documents clinical data, assessments, procedures, and patient education according to Orlando Health and department specific policies.
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician or APP.
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.
Supports and demonstrates effective and professional communication with patients and family members
Adheres and assures compliance with Orlando Health and department specific policy, procedures, value statements and Commitment to Excellent standards.
Consistently demonstrates personal and patient safety practices and adherence to infection control standards outlined in Orlando Health policies.
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
Other Related Functions
Demonstrates awareness of medical/legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.
Assists business office as needed with reception, scheduling, and discharge of patients.
Qualifications:
Education/Training
High school graduate or equivalent.
Licensure/ Certification
Successful completion of an Orlando Health clinical documentation training program or Scribe training program within 60 days of hire.
Experience
One (1) year of experience in a health care related position or health related education.
Skilled in operating various medical record software and hardware, word-processing, and database software program
Job Tags
Permanent employment, Local area,