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Clinical Documentation Specialist
2 months ago
Orlando Health Medical Group is seeking a highly skilled Clinical Documentation Specialist to join our team. As a Clinical Documentation Specialist, you will play a critical role in facilitating efficient and effective medical care between patients and clinical team members.
Key Responsibilities- Gather and document 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.
- Prepare and assemble medical record documentation/charts for physician(s).
- Enter the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
- Ensure medical record compliance by self-documentation attestation.
- Update patient history, physical exam, and other pertinent health information in the patient.
- Prepare and send all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
- Monitor the duration of basic lab results and screening procedures.
- Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
- High school graduate or equivalent.
- Successful completion of an Orlando Health clinical documentation training program or Scribe training program within 60 days of hire.
- One (1) year of experience in a healthcare-related position or health-related education.
- Skilled in operating various medical record software and hardware, word-processing, and database software programs.
