Clinical Scribe

Work Shift

Day/Evening

Scheduled Weekly Hours

0

Summary

This position supports Mercy’s philosophy of patient centered care by facilitating the delivery of health care services by providing knowledgeable support to the physician or provider in all aspects of patient care. This includes all interactions with patients and their families; in person during the clinic visit, telephonically and electronically. In addition, this position provides real-time charting, ensuring an accurate and completed medical record for each patient visit.

Job Description

Job Duties

• Prepares the progress note for the patient visit by manually bringing in provider-built EPIC documentation tools for the following sections: history of present illness, review of system, physical exam, assessment and plan. Ensures health maintenance section (including quality reporting measures) and immunizations are up to date.
• Rooms and prepares the patient for examination. This includes reviewing histories, allergies, medications, reason for visit and taking vitals.
• Per established standing orders of provider, orders/administers injections, orders/collects specimens for lab testing (ex. Rapid strep tests) and performs phlebotomy as needed. Provides test results as directed by Provider.
• Populates patient-reported information into provider-built EPIC documentation tools for the specific disease states and preventative visits.
• Communicates a summary of the patient-reported information to the provider prior to entry of the room or within the room with the patient present.
• Accurately and thoroughly documents the encounter with the patient as it is being performed by the provider, which may include documentation in the following sections: problem list, history of present illness, review of systems, physical exam, assessment and plan, procedures and treatments performed by team, patient education, orders, medications, referrals, explanations of risks and benefits, and instructions for self-care and follow-up. Identify the portions of the encounter that were scribed on behalf of the provider using the scribe signature per policy.
• Provides patient instruction using pre-approved patient education materials specific to the chief complaint or for the health promotion of observed behaviors known to contribute to poor health, as directed by the provider
• Prints after visit summary and completes discharge of patient from exam room. This may include scheduling a follow-up appointment, providing referral information or scheduling patients for testing procedures and providing instructions.
• Manages phone calls to patients regarding test/lab results and provides appropriate instruction for treatment, as directed by the provider.
• Processes medication requests/changes/refills per established written protocols. This includes having knowledge of medications, including basic dosages, side effects and interactions.
• Provides assistance with diagnostic procedures (ex. EKGs) and treatments (ex. Nebulizer treatments) as directed by the provider. This includes obtaining specimens, labeling and disposition to the laboratory and explaining diagnostic procedures to patient as needed.
• Prepares the exam and treatment rooms, including instrument, supplies and protective devices for exam and testing.
• Performs other duties as assigned.
• Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.

Knowledge, Skills and Abilities

• Working knowledge of medical terminology, anatomy & physiology, pharmacology, treatment assessments and accepted abbreviations.
• Recognition of physical exam process and ability to record exam details.
• Computer proficiency, including keyboarding, Microsoft Office and Electronic Medical Record.
• Proficient in typing, spelling, punctuation and grammar.
• Organization skills with focus on tracking patient care and improving patient flow.
• Professional demeanor and recognition of privacy considerations for patients and families.
• Familiar with other office equipment including fax machine, phone and copy machines
• Must have the ability to refer to reference materials to solve problems
• Ability to apply logic and draw conclusions based on knowledge

Professional Experience

• Preferred: Three to five years relevant experience.
• Required:  Successfully completed clinic transformation with assigned provider to include:  scribe training and go live support; or hired directly into a provider area that has already implemented clinic transformation.  The nurse wil be trained as a clinical scribe immediately upon hire.

Education

• Education sufficient to obtain required licensure

Licensure, Certification, Registration

• Required: Registered Nurse
• Current certification in Basic  Life Support (BLS), in accordance with the American Heart Association required.
• Iowa Dependent Adult Abuse and Iowa Child Abuse Mandatory Reporter Training required.  Employee must submit certification of completed training to Human Resources prior to start or transfer date.

Physical Requirements

Medium:
Must be able to lift up to 50# on occasional basis to assist with patient transfers.
All lifting over 50# should be performed with team lifts.
Able to push and pull of up to 25# of horizontal force on occasional basis and push and pull up to 40# of horizontal force on rare basis.
Ability to administer CPR

Pay Rate Type

Hourly

Mercy is an independent, community-based organization supporting the Cedar Rapids area for over 120 years.

Mercy is an equal-opportunity employer. We value diversity, equity, and inclusion and therefore evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status, and other legally protected characteristics.