Overview

Overview:

Obtain vital signs and general health information for patient chart and prepares patient for examination.  Assists the provider as needed with examinations and procedures.  Assists in the collection of laboratory specimens and performance of tests on patients as ordered by the provider or arranges for patient testing, admissions and referrals.  Enters and records patient information in charts in a concise and accurate manner.  

Responsibilities

Position Specific Competencies:
In addition to the following essential position competencies, other competencies may be required to meet
changing organization needs.
1. Uses an appropriate problem-solving approach to plan services.
a. Obtains vital signs and general health information for patient chart and prepares patients
for examination.
b. Maintains patient health record in an up-to-date status especially regarding pain assessment
and current medication sheet.
c. Assures documentation is complete, concise and correct.
d. Prepares and maintains exam rooms and medical equipment for patient visits
e. Contributes to plan of care for individuals and groups of patients utilizing all principles
to reduce medication errors when handling or calling in medications or refills.
f. Demonstrates initiative in suggesting and implementing problem solving approaches and
planning performance of service.
g. Prepares and maintains exam rooms and medical equipment for patient visits regarding
all safety checks and HIPAA guidelines and adapt same HIPAA principles to chart
documentation and exposure as well as discussing PHI in front of anyone other than
patient.
h. Triages patients and enters accurate and concise data into the EMR while paying
attention to spelling and clarity.
i. Navigates the EMR system in an efficient manner.
j. Facilitates quality care management thru best practice utilization of the clinic EMR.
k. Promotes continuity of care seen by appropriate actions notes and prompt follow up.
l. Answers phones, routes calls and or takes accurate message. Demonstrates a sense of
urgency relating to patient's level of distress.
m. Triages basic patient care needs, generating a telephone encounter depending upon the
situation. Assure a duplicate message has not already been started.
n. Identifies barriers related to Social Determents of Health (SDOH) and notifies provider.
o. Forwards requests for Medical Records to Release of Information Department.
p. Recognizes how fraud and abuse interplay into daily role.
q. Ensures orders are entered correctly to capture appropriate charges.
r. Identifies barriers germane to patient's individual needs being financial, emotional,
physical, cultural or spiritual (SDOH).
s. Astute and sensitive to patient satisfaction as it pe1iains to customer service- people
skills in all clinical situations.
2. Provides services with consideration of the recipient's needs.
a. Ensures that patients are placed in exam rooms and seen by the provider in a timely
manner.
b. Assists the provider as needed with examinations and procedures
c. Ensures the smooth transition of patients
d. Assists in the collection of laboratory specimens and performance of tests on patients as
ordered by the provider. Track lab and all tests for outcomes and follow-up.
e. Identifies clinical significance of data and informs provider appropriately and provides
follow up accurate documentation.
f. Ensures that all lab results, interpretations, etc. are received in the patient charts in a timely
manner. Always assesses for provider signature, patient notification, date and any required
follow up.
g. Actively participates in department functions by suggesting strategies to improve outcomes,
control cost, and or increase patient satisfaction
h. Maintains work area in neat organized manner.
i. Secures patient information in desk drawers orfolders.
j. Greets and direct patients and visitors in a courteous manner, informing them of delays or
changes in patient flow.
k. Manages appointment schedule to ensure provider efficiency and patient satisfaction.
l. Monitors the reception area to ensure patient comfort and prompt response to patient distress or
concerns
m. Wears FH name badge and introduces self to patient as needed and required by the situation.
3. Uses equipment/supplies correctly.
a. Ensures that equipment and other instruments are properly set up for the providers' use.
b. Maintains the medical supplies necessary for providers to perform their examinations.
4. Uses appropriate safety and infection control measures.
a. Ensures that all OSHA regulations and other appropriate policies are followed
b. Actively participates in the established QI/Risk Management Program.
c. Wears gloves and follows Body Substance Isolation Standards whenever examining the
patient or contacting blood or body fluids
d. Ensures all needles are placed in sharps containers and all material with blood or body fluids
are disposed of properly
e. Ensures that all exam rooms and equipment are properly cleaned between patients.
5. Teaches/directs/advises/informs others in an appropriate manner.
a. Serves as communication link between the patient and the provider
b. Administers prescribed medications as directed and instructs patients on the proper use of each
medication
c. Accurately and clearly communicates data to the appropriate healthcare provider in a timely
manner.
d. Assists office personnel with scheduling and preparing follow-up appointments as germane to
clinical co-morbidities.
e. Arranges for patient testing, admissions and referrals
f. Teaches patients according to provider's instructions and in conjunction with age appropriate
guidelines
g. Utilizes EMR to support patient education and documents accordingly.
6. Reports/records information appropriately.
a. Enters and records patient information in EHR in a concise and accurate manner.
b. Ensures that all test results, interpretations, etc. are received in patient EHR in a timely
manner.
c. Uses approved format for recording and reporting messages. i.e. telephone encounter, etc.
d. Maintains written repo1is of all situations requiring manager's attention
e. Enters and records patient information in EHR in a concise and accurate manner, paying
attention to lot number and expiration date, patient tolerance of injections, proper
consent forms, and authorizations on file.

Qualifications

Education/formal training/licensure/certifications/experience:
Must have a valid NC LPN License, NC Paramedic or AEMT Certification, or CMA Certification. Minimum one year of work experience in a primary care medical clinic or similar environment preferred.