Physician Documentation Assistant

Location: Steward Medical Group - North

Posted Date: 6/17/2021

Steward Medical Group at Hawthorn Medical Associates is looking for an enthusiastic, dedicated Physician Documentation Specialist (PDS) to assist our providers in the treatment of patients. The successful candidate will:

• At the physicians discretion, the PDS may accompany the supervising physician during a patients history taking and examination.
• The PDS will record onto the electronic medical record (Athena) the details of the patients visit as directed by the physician. The physician may elect to personally document any part of any patients record, or to complete it in its entirety.
• The PDS, at the direct request of the physician, may elicit and record elements of the medical history, social and family history through direct questioning of the patient and or the patients family. In such cases, the physician must personally confirm this information to his/her satisfaction.
• The PDS may assist the physician with researching and recording a patients PMH by reviewing notes, reports, referral notes from other health care facilities, and hospital records (e.g., prior admission notes, discharge summaries, operative/procedure notes and ED records).
• The PDS will enter all orders for patient care utilizing electronic medical record (Athena). The PDS will enter orders as a delegate of the physician.
• The PDS will record all discharge documentation, including personalized discharge instructions, referrals, work/school notes and prescriptions.
• Ability to read and write English
• Knowledge of medical terminology; familiar with Electronic Medical Records
• Ability to successfully interact with medical staff, patients, and families
• Ability to maintain confidentiality and conform to all standards of HIPAA, compliance and privacy regulations

Qualifications:

• Open to current employees in good standing
• Certified Medical Assistant with at least 2 years relevant experience, preferably in an orthopedics practice setting