Documentation Assistant, High Point Premier Pain Clinic

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Wake Forest Baptist Health
May 13, 2021
Wake Forest, North Carolina
Job Type


Job Description
Job Title:
Documentation Assistant, High Point Premier Pain Clinic
Job ID:
Full/Part Time:
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Major Duties

JOB SUMMARY: Guides patients through the clinic appointment with a positive, comprehensive, personalized experience that is focused on achievement of clinical goals. Overall duties include preparation for the patients clinic visit by abstraction of a broad range of data from their medical record; validate data during the visit to identify gaps in care and assist in the design of an individualized care plan based on clinical goals; perform various patient treatments as necessary; provide detailed information and instruction to the patient at the conclusion of the visit; perform clerical, environmental and organizational tasks within the practice as necessary, including appointment scheduling and chart management; serve as data entry specialist during the provider encounter, including assessment and plan of care in compliance with regulatory guidelines.

EDUCATION/EXPERIENCE: High School Diploma or GED equivalent.  Previous experience in medical practice preferred.

REPORTS TO: Service Line Leadership, Practice and/or Nurse Manager

LICENSURE, CERTIFICATION, and/or REGISTRATION: AAMA, AMT, CCMA, or NCMA certification or registration required. Basic Cardiac Life Support (BCLS) required. Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS) may be required within one year in select areas.


1.   Participates in daily Care Team Huddles to ensure collaborative care is given to each patient on every visit.

2.  Performs review of patient?s medical records for upcoming, scheduled clinic visit.  Abstracts pertinent data related to activity within the healthcare system since last visit, quality indicators and the patient?s personal clinical goals of therapy. Makes notes as necessary to serve as a reminder of issues that need to be addressed during the clinic visit.

3.  Obtains and documents all pertinent vital signs and measurements. Screen patient?s medication regimen in detail to evaluate each medication and dosage currently in the electronic health record (EHR) and any newly reported medications or dosages.  Notes any discrepancies to discuss with provider. Reconciles allergies. Performs routine screenings per patient population and reports results to provider.

4.  Engages patient in conversation regarding reason for visit and overall health. Screens patient?s social environment, gaps in care, quality measures and progression and/or barriers to reaching the goals of therapy. Documents reason for visit, review of systems and history of present illness.

5.  Prepares chart with any labs or other data for ease of access for provider, including reminders for quality indicators.

6.  Assists providers with examinations, diagnostic procedures and treatments.

7.  Remains in the exam room, enters all findings with the exception of the physical exam, including history of present illness, review of systems, assessment, and plan in the provider notes. Enters provider orders and plan of care instructions, including prescriptions.  Provides instructions to patient and educational materials based on the exam findings.  Informs patient for timing of next visit and directs to check out for scheduling.

8.  Documents all activities/interventions, patient/family responses, medication dispensed/prescribed in the EHR.

9. Fulfills other patient care responsibilities as assigned that may include checking schedules and organizing patient flow; assisting patients as needed with walking, transfers, dressing, collecting specimens, and preparing for exam.

10.  Fulfills clerical responsibilities as assigned. May include sending/receiving medical records and reports; facilitation of referrals; completing forms and requisitions and scheduling follow up appointments as needed.

11.  Enhances professional growth and development through participation during in-service meetings, educational programs, conferences, and participate in committees as requested.  Adheres to North Carolina?s controlled substance regulations.

12.  Practices universal precautions and properly handles blood and body fluids in accordance with organizational policies and procedures.

13.  Completes training related to hierarchical condition category (HCC) coding and demonstrates competency by appropriately documenting when transcribing patient visits.

Knowledge of computer systems and applications
Advanced typing and navigation skills within the electronic medical record system
Critical thinking skills
Excellent oral and written communication skills
Advanced knowledge of medical terminology and disease specific goals of treatment
Knowledge of medical documentation guidelines and practices including legal responsibilities related to confidentiality
Competence in English grammar, punctuation, and spelling
Knowledge of standard concepts, practices, and procedures within the designated field
Knowledge of organizational policies, procedures and protocols
Knowledge of common safety hazards and universal precautions to establish a safe work environment

Generic Job Description

Combination of medical office and exam/procedure room settings
Well-lit, well-ventilated, and adequate space
Frequent exposure to diseases, medicinal preparations and other conditions common to a clinic environment

The physical demands and work environment characters described are representative of those that must be met by an employee to successfully perform the essential function of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands require full range of body motion and knowledge of proper body mechanics including handling and lifting patients, finger dexterity and hand-eye coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 40 pounds, also in certain circumstances could have to support, assist, or turn patients weighing up to 300 pounds. Requires ability to transport patients weighing up to 300 pounds via wheelchair (equivalent of 50 pounds pushing pressure). Requires corrected vision and hearing to normal range. Requires ability to work under stressful conditions demanding high concentration and energy level.

Amount of time spent performing the following activities:
0% 35% 65%
to to to
35% 65% 100% N/A Activity
x Standing
x Walking
x Sitting
x Bending
x Reaching with arms
x Finger and hand dexterity
x Talking
x Hearing
x Seeing
Lifting, carrying, pushing and or pulling:
x 20 lbs. maximum
x 50 lbs. maximum
x 100 lbs. maximum

How to Apply

To apply for this position, please click on the "Apply Now" button on this page.  You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina  27104. You may also call our office for assistance at (336) 716-6464.  Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at

Equal Employment Opportunity

It is the policy of  Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

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