Prepares and rooms the patient for exam by obtaining vital signs and gathering/documenting/updating pertinent health information (i.e. chief complaint, allergies, and/or medications).
Performs laboratory procedures (i.e. strep test, wound culture, specimen collection, etc.) using principles of aseptic technique and standard precautions/infection control guidelines.
Assists the physician/advance practice provider (APP) with procedures and surgeries such as pelvic exams, allergy scratch testing, EMG, cautery, colposcopy, etc.
Administers routine medications, under physician/APP orders, which may include but are not limited to immunizations, antibiotics, vitamins and topical agents.
Provides basic patient instructions on the performance of routine tasks or skills. Follows through with necessary procedure or test requests, pre-approved care algorithms, new appointment times and referrals to other facilities or services. Refers questions to registered nurses and physicians/providers per scope of practice guidelines and relays information back to patient as directed.
Communicates with physicians and other members of the health care team to ensure smooth clinic flow and makes adjustments as necessary. Effectively communicates accurate and timely information with the patient.
In accordance with policy, prepares and assembles medical record documentation/chart for physician prior to patient visit. Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results. Ensures that all elements of documentation are complete and accurate.
Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications. Documents the physician/clinician's communication with the patient using appropriate medical terms and phrasing.
Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders. Documents the correct follow-up instructions and level of service designation based on the physician/clinician's direction. Assists in data entry from devices or other sources.
Completes medical records for each encounter ensuring accurate and timely documentation. Under physician/clinician direction, updates patient history and other pertinent health information in the patient record. Prepares and sends all documentation for review and approval.
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
Typically requires 1 year of experience in medical assisting, medical transcription, emergency medical services, patient service and/or as a health care professional with demonstrated proficiency in medical terminology and technical spelling.
LPN: Licensed Practical Nurse (LPN) license issued by the state in which the team member practices, and
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required.
MA: Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required.
LPN: Advanced training beyond High School that includes the completion of an accredited or approved program in Practical Nursing
MA: Completion of an accredited or approved program in Medical Assistant
Knowledge, Skills & Abilities Required:
Physical Requirements and Working Conditions:
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.