shenandoah Work Opportunities ∙ Page 2

1. Assesses overall health status of patients through health history, physical examinations and diagnostic testing.

• Performs initial and ongoing participant assessments, care plan development, and implementation of care plan.
• Obtains a complete health history and records the findings in a systematic organized manner. Performs physical examinations, orders and evaluates appropriate laboratory and diagnostic tests, and records in a systematic manner.
• Identifies medical, social, cultural, and financial problems.
• Performs functional status evaluation and/or mental status examinations using standardized procedures.
• Identifies and describes behavior patterns of the chronically ill.
• Triages status changes in participants and facilitates appropriate management of problem identified.
• Exercises final medical judgment in all issues of healthcare.
• Conducts physical examinations to provide information needed for admission to school, consideration for jobs, or eligibility for insurance coverage.
• Provides prenatal care to pregnant women, delivers babies, and provides postnatal care to mother and infant.
• May performs minor surgery.

2. Completes and maintains comprehensive and accurate practice and Hospital medical records, including dictation, in a timely manner on each patient encounter.

• Completes medical records and dictation after each patient encounter in an accurate and timely manner to facilitate billing, appropriate communication with patient and healthcare professionals, as well as coordination of care with other Physicians and healthcare providers.
• Cooperates with chart audits, reviews, and education as requested.
• Cooperates with coding staff, nursing staff, other allied health professionals, and administrative staff to clarify or assist with administrative follow-up as necessary to facilitate prompt billing.
• Participates in coding audits and education as requested.

3. Educates patients on wellness, prevention and early detection by providing materials and resources to the patients and families.

• Educates clients and families regarding health maintenance and applicable chronic medical conditions in cooperation with nursing staff.
• Provides inpatient attending coverage responsibility when necessary.
• Serves as a source of medical knowledge for the hospital.
• Provides consultation to nurse clinicians and nurse practitioners.

 4. Prescribes medication in accordance with Iowa statute and professional practice guidelines.

• Prescribes medical treatment and clinical drugs to patients.
• Documents all services in patient’s medical record.
• Reviews on a regular basis, long term cases that require ongoing medical attention.
• Determines level of urgency of follow-up, referral/consultation appointments.
• Determines which referrals are required based on examination and patient needs.
• Inoculates and vaccinates patients to immunize patients from communicable diseases.

5. Communicates effectively.

• Communicates and collaborates effectively with other health team members regarding patient condition, nursing plan of care, patient satisfaction needs and recommendations for meeting identified outcomes.
• Reports births, deaths, and outbreak of contagious diseases to governmental authorities.

 6. Promotes and ensures patient and staff safety in all aspects of responsibilities.

• Implements infectious disease controls as appropriate including isolation procedures, proper use of hand washing and gloves.

7. Performs other duties as assigned.