Clinical Scribe - RN - General Surgery (1.0 Days)

Mercy Cedar Rapids•Baltimore, MD

1d•Onsite

About The Position

This position supports Mercy's philosophy of patient centered care by presenting excellent customer service and enables the facilitation of positive patient outcomes by providing nursing support to a Mercy provider. The Clinical Scribe prepares the progress note for the patient visit by manually bringing in provider-built EPIC documentation tools for various sections. They ensure health maintenance and immunizations are up to date, room patients, and prepare them for examination by reviewing histories, allergies, medications, and reason for visit, and taking vitals. The scribe may order/administer injections, order/collect specimens for lab testing, and perform phlebotomy as needed, and provides test results as directed by the Provider. They populate patient-reported information into provider-built EPIC documentation tools and communicate a summary of this information to the provider. The scribe accurately and thoroughly documents the encounter with the patient as it is being performed by the provider, identifying scribed portions with their signature per policy. They provide patient instruction using pre-approved materials, print after-visit summaries, and complete patient discharge from the exam room, which may include scheduling follow-up appointments or procedures. The scribe manages phone calls to patients regarding test/lab results and processes medication requests/changes/refills per established protocols, demonstrating knowledge of medications. They provide assistance with diagnostic procedures and treatments, prepare exam and treatment rooms, and perform other duties as assigned. The role also requires following Mercy's safety guidelines and promptly reporting any unsafe conditions.

Requirements

Education sufficient to obtain RN licensure required.
Current license to practice as registered nurse in the state of Iowa or compact state required.
Current certification in Basic Life Support, in accordance with the American Heart Association required.
Iowa Dependent Adult Abuse & Iowa Child Abuse Mandatory Reporter training required.
Excellent communication and customer service skills
Computer skills
Organization
Time management
Attention to detail
Ability to remain poised and efficient in a fast-paced environment.

Nice To Haves

Previous experience in a medical office setting preferred.

Responsibilities

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.