MG Physician Documentation Assistant

1. At the physician*s discretion the PDA may accompany the supervising physician during a patient*s history taking and examination. The physician will personally elicit the patient*s HPI which may be recorded by the PDA.
2. The PDA will record onto the ED medical record the details of the patient*s visit as directed by the physician. The physician may elect to personally document any part of any patient*s record or to complete it in its entirety.
3. The PDA 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 patient*s family. In such cases the physician must personally confirm this information to his/her satisfaction.
4. After the PDA and the physician leave a patient*s room the physician will review the documentation entries recorded by the PDA during the encounter and will make any and all necessary amendments to the patient*s medical record so that it is accurate and complete. The physician retains exclusive responsibility for the documentation of all patient care information recorded by the PDA during each patient encounter and at all other times.
5. The PDA may assist the physician with researching and recording a patient*s PMH by reviewing nurse*s notes EMS reports referral notes from other health care facilities and hospital records (e.g. prior admission notes discharge summaries operative/procedure notes and ED records).
6. The physician will personally enter all orders for patient care utilizing Computerized Physician Order Entry (CPOE). PDAs will not enter such orders.
7. All medication and nursing orders for patient care are to be personally communicated to a nurse directly by the physician and not by a PDA.
8. The physician will personally complete each patient*s discharge documentation including personalized discharge instructions pre-printed/standard discharge instruction sheets referrals work/school notes and prescriptions. PDAs are not to perform this function.
9. The physician will sign each patient*s medical record when it is complete and after he/she has reviewed and if necessary amended the document for accuracy.
10. The PDA may advise the physician when test results are available when a patient is ready for disposition (i.e. all tests are resulted) when a critical value has been flagged/reported when a patient is ready for a procedure (i.e. the appropriate cart is in the room and ready for use) and when there has been a delay in completion of ordered tests (e.g. a urine has not been obtained blood has not yet been drawn etc.).
11. The PDA may perform a *patient ambassador* function on behalf of the physician checking to see if patients are comfortable have had adequate pain relief etc. The PDA may obtain blankets and pillows for patients as well as nourishment (following approval by the physician or the patient*s nurse). The PDA will inform the physician if the patient has pain nausea or any other condition or request that requires attention.
12. The PDA may serve as a liaison between the physician and nurses and other hospital staff by forwarding messages between the parties (e.g. a request by the physician to prepare a patient for suturing). The PDA may not communicate messages regarding direct patient care (e.g. medication or IV orders).

Ability to read and write English

Familiarity with Electronic Medical Records

Ability to successfully interact with medical staff patients and families

Ability to maintain confidentiality and conform to all standards of HIPPA compliance and privacy regulations

Knowledge of medical terminology a must

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

High school diploma; bachelor's degree preferred with PDA experience; current medical students encouraged to apply.