Clinical Coding Trainee
临床编码培训生
Position Title: Trainee (will become Clinical Coding Specialist)
职位：培训生（将来成长为临床编码专员）
Immediate Supervisor: Coding Supervisor
直接上级：编码主管
Position Purpose:
工作目的：
The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing.
这个职位的设立是为了将适合的诊断和程序上的编码运用于个体病人的健康信息的数据检索，分析和索赔处理
Responsibilities:
职责：
Abstracts pertinent information from patient records. Assigns standard international code (called the ICD code)
从病例报告中提炼出相关信息，并编辑成标准的国际码—名为ICD 码。
Fills out physician query form when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
当不能直接进行编码的编写或病例中的文档是不适当的，含糊不清的或者对于编码目的来说是不清楚的，填写医生问题表格
Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified
concerns to supervisor for resolution.
跟随编码指南和偿还报告的要求。将相关的信息呈递给主管帮助其做正确的决策
Abides by the Standards of Ethical Coding and adheres to official coding guidelines.
遵守“标准的编码道德”和公布的官方编码指南。
Requirements:
任职要求
Have taken most or all of the following courses: Medical terminology, Anatomy and physiology, Pathophysiology(Disease processes), and Pharmacology
学习过大部分或全部的下列课程：医学术语，解剖和生理学，病理生理学（疾病进程），和药理学
Must study and complete certification test successfully completion of a international coding certificate program (information will be provided on how to do this.)  This certification will require a significant time commitment.
必须学习并取得证书，证明其成功完成一个国际编码测试程序（将会提供关于如何操作的信息）这个证书将需要一段时间的学习。
Must be able to read English medical record (A sample is below.)  If the applicant can not read 75% of this without medical dictionary, they are not eligible.
必须能够读懂英文的病理报告（下附带范例）。如果申请者不能在没有字典的帮助下读懂75%以上的内容，将不予考虑其申请。
英文病理报告如下。
The patient was seen by me at approximately 4:30 a.m. on the 17th of September 1995.
CHIEF COMPLAINT: The patient complains of chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening.
The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took oneofhis own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department.
Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable.He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time.
PAST MEDICAL HISTORY: The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines.
ALLERGIES: None.
CURRENT MEDICATIONS: Include nitroglycerin p.r.n.
•  PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5.
GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed.
HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact.
NECK: Supple with full range of motion. No rigidity or meningismus.
CHEST: Nontender.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmur, S3, or S4.
ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Unremarkable.
EMERGENCY DEPARTMENT LABS: The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%.
EMERGENCY DEPARTMENT COURSE: The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter.
AFTERCARE AND DISPOSITION: The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activityuntil then. The patient left with final diagnosis of:
FINAL DIAGNOSIS:
1. Evaluation of chest pain.2. Possible esophageal reflux
工作地点：北京市中关村
教育背景：医学类院校毕业生
招聘人数：10
月    薪：5000元
电子邮箱：swzp2010@sina.com (请勿以附件形式发送简历)