What are the responsibilities and job description for the Medical Record Tech. position at Oroville Hospital?
Job Description
- High school graduate or equivalent
- Medical Office or Hospital experience preferred.
- Completion of sophomore year of college in pre-med, nursing, EMT/Paramedic, Chemistry/Biology or other professional or allied health field preferred.
- Medical Terminology and Pharmacology preferred.
- American Heart Association (AHA) Basic Life Support (BLS) Provider certification or American Red Cross Basic Life Support for Healthcare Providers certification
Start Date:
Open Until Filled.
Qualifications:
- High school graduate or equivalent
- Medical Office or Hospital experience preferred.
- Completion of sophomore year of college in pre-med, nursing, EMT/Paramedic, Chemistry/Biology or other professional or allied health field preferred.
- Medical Terminology and Pharmacology preferred.
- American Heart Association (AHA) Basic Life Support (BLS) Provider certification or American Red Cross Basic Life Support for Healthcare Providers certification
Duties &
Responsibilities:
Job Summary
Under the direct supervision and presence of the Practitioner (Physician and/or Mid-level Provider), the Medical Record Tech provides annotation, in the Electronic Health Record (EHR) of any dictated, written, or verbally communicated information for the treatment of patients following all local, state and federal regulations/guidelines for documentation. The Medical Record Tech will be responsible for clearly recording the procedure performed in the operating room as dictated by the provider. The Medical Record Tech is not a direct patient care provider.
Duties
- Available to all surgeons in the operating room to assist in documenting the operative report, post op orders and instructions.
- Transcribes under the direction of provider, patient orders, including laboratory tests, imaging tests, etc.
- Completes the procedure/operative note on behalf of the provider as directed.
- May look up pertinent past medical records at the direction of the provider.
- Keeps track of and enters the results of imaging studies as directed by the provider.
- Enters documentation on patient progress as directed by provider.
- Lists proper diagnosis as well as any discharge/follow-up instructions and prescriptions, as dictated by the provider.
- Follows documentation compliance standards.
- Assures that the Electronic Health Record is complete and that all pertinent documentation requirements are met, including the diagnosis, disposition and patient education interventions.
- Ensures the provider reviews the Electronic Health Record for accuracy. Obtains provider signature, under the provider’s profile, for each encounter.
- Develop and maintain a mutually respectful working relationship with all providers.
- Available for provider concerns and questions and is ready to assist in documentation at all times.
- The Medical Record Tech does not participate in any patient care and should refer all requests to participate in any patient care to the provider or nursing staff.
- Other duties as assigned.
Skills/Abilities
- Demonstrated ability to work well under pressure in a critical environment and maintain attention to detail in order to accurately document encounter.
- Demonstrated observation, listening, interpersonal, and clarification skills in order to interact positively and productively with provider and patient.
- Demonstrated knowledge of computers and technology.
- Demonstrated ability to multi-task and organize.
- Demonstrated excellent verbal and written communication skills.
- Demonstrated strong desire to learn.
- Ability to maintain confidentiality.
- Must be able to type on a keyboard at least 40 wpm, with ability to increase speed while maintaining accuracy.
Experience
- Demonstrated experience working with medical providers and allied health professionals.
- Knowledge of medical terminology, anatomy and physiology preferred
Other Info:
Lifting Requirements: Generally lifting not more than 10 lbs. and occasionally lifting up to 25 lbs. Frequent bending, standing, pulling and pushing.
Job Posted:
01/15/2025
Contact Name:
Human Resources
Contact Phone:
530.712.2137
Contact Email:
hrrecruiting@orohosp.com
Salary : $20 - $26
