Records medical details, gathers data, and coordinates tests, orders and results as necessary to ensure an accurate and complete medical record. Assembles and maintains patients' health information in medical records and charts by assisting medical providers and physicians. No medical decision making is performed.
Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies in to the medical record system.
Accompanies physician into patient examination area in order to transcribe a history and physical examination as given by the patient and physician or medical provider.
Records details of physical exam, including pertinent positive and negative noted abnormalities and patients general condition in the medical record system.
Validates test results are received and reviewed during patient visit as directed by medical provider.
Coordinates tests, orders, and results to ensure all health information is recorded accurately and ready for access by the medical provider.
Lists all proper diagnoses as well and any discharge/follow up instructions and prescriptions as dictated by the physician or medical provider.
Maintains confidentiality of all patient information.
Ensures that provider has signed their own dictation and super-bill.
High school diploma/GED or equivalent working knowledge.
Two years of experience in acute care or multi-specialty clinic using electronic medical record software or maintaining medical records.
Additional related education and/or experience preferred.
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system incl...udes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many locations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.