POSITION OVERVIEW: Ensures that documentation meets appropriate coding requirements. Assists the Emergency Department (ED) physician with documentation of each patient's medical chart during his or her stay. Accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician. Under the direction of the ED physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc. Transcribes any consultations or discussions with family and/or the patient's private physician or the on-call physician. Completes the patient's chart by transcribing results of any labs, x-rays, or other evaluations. Continuously checks on the progress of patient chart data in order to get the patient's workup complete so that the physician is able to make his or her decisions regarding that patient. Lists all proper diagnoses as well as any discharge/follow up instructions and prescriptions, as dictated by the physician.
ADDITIONAL QUALIFICATIONS AND/OR REQUIREMENTS: One to three years' experience and knowledge of medical techniques and terminology preferred. Current enrollment in a medical-related secondary degree program preferred. For pre-med students, completion of a medical terminology course preferred.