Locates specified clinical data for abstraction from various forms of medical records through intensive medical record review. Abstracts clinical information and inputs it into the electronic medical record.
1. Enters patient data into electronic health record and/or make corrections to information entered.
2. Responds to inquiries regarding data.
3. Ensures a high degree of accuracy of information entered.
4. Works with Practice physicians and clinical staff to set abstraction appointments, pulls charts according to the protocol and arranges for all necessary tools to conduct abstractions.
5. Represents PAANS Transformation Team and members interest in supporting physicians to improve AEHR adoption and use.
6. Provides accurate and prompt post-assessment findings to the Practice abstracting project lead and to PAANS HIM.
7. Aggregates summary data, tracks routine statistics, conducts analysis and completes standard reports.
8. Carries out routine correspondence.
9. Performs related duties, as require
- High School Diploma or equivalent, required. Graduate from an accredited School of Nursing or Physician Assistant Program, required.
- Current license to practice as a Registered Professional Nurse or Physician Assistant in New York State, required.
- Previous experience with medical records and/or abstracting experience, preferred.
- Strong organizational skills, required. Knowledge of general office procedures and Microsoft Office.
- Excellent written and oral communication and interpersonal skills, required.