Physician Documentation Assistant (PDA)

Position Summary: The Physician Documentation Assistant (Scribe) provides clerical support to the staff physician, with specific goals of improving throughout for all patients. The primary role of the scribe will be to work along-side the physician and transcribe all appropriate physician documentation, in addition to other clerical duties. This assistance is under the direct oversight and control of the staff physician and the Nurse or Office Manager.

Responsibilities:

• Models professional practice through collaboration with staff, leadership, patients, families and physicians.
• Interacts in a positive, professional manner with evidence of conflict resolution skills.
• Documents physician assessment accurately, timely, and without subjectivity.
• Documents any procedures completed by the physician.
• Reviews all assigned patients for updated testing results and promptly reports them to the assigned physician.
• Receives/relays all forms of communication accurately, promptly, courteously, and to the appropriate personnel/department.
• Assists with Clinic Office Assistant duties as needed

Qualifications: 

Required:

• High school graduate or equivalent.
• Basic computer knowledge
• Strong organizational skills, excellent communication skills, prioritization skills, the ability to work well under stress and the ability to think critically and problem solve. 
• Minimum of:
  • 6 months previous patient care experience or;
  • Student in Nursing, Allied Health or Medicine or; 
  • Completion of medical terminology class.
• Capable of multitasking and prioritizing workload. 

Preferred:

• Experience with the order entry functionality in healthcare information systems is desired.
• Allied health experience with credentials such as: Registered Health Information Technician (RHIT) certification ; Certified Medical Transcription (CMT) certification; Certified Nursing Assistant (CNA).

Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment.

Patient Interaction: Frequent

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical

Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates