CMA - Vernon Village - Full-Time

Mercy Cedar Rapids•Village of Vernon Hills, IL

About The Position

The Clinical Scribe supports Mercy’s patient-centered care philosophy by facilitating healthcare services and providing knowledgeable support to physicians or providers throughout patient care. The role involves interactions with patients and families in person, by phone, and electronically, as well as real-time documentation to ensure an accurate and complete medical record for each visit. The Clinical Scribe prepares and maintains visit documentation in EPIC, helps room and prepare patients, performs clinical tasks under provider standing orders, communicates patient-reported information to providers, and assists with patient education and discharge. The position also supports diagnostic procedures, treatment, laboratory workflows, medication requests, and exam-room preparation.

Requirements

Currently licensed to practice as a Licensed Practical Nurse in Iowa.
Current Basic Life Support (BLS) certification in accordance with the American Heart Association.
Complete Iowa Dependent Adult Abuse and Iowa Child Abuse Mandatory Reporter training, and submit certification to Human Resources before the start or transfer date.
Successfully completed clinic transformation with an assigned provider, including scribe training or go-live support; alternatively, hired directly into a provider area that has already implemented clinic transformation. LPNs will be trained as Clinical Scribes immediately upon hire.
Working knowledge of medical terminology, anatomy and physiology, pharmacology, treatment assessments, and accepted abbreviations.
Ability to recognize the physical examination process and record examination details.
Computer proficiency, including keyboarding, Microsoft Office, and electronic medical records.
Proficient typing, spelling, punctuation, and grammar.
Organization skills focused on tracking patient care and improving patient flow.
Professional demeanor and awareness of patient and family privacy considerations.
Familiarity with office equipment such as fax machines, phones, and copy machines.
Ability to refer to reference materials to solve problems.
Ability to apply logic and draw conclusions based on knowledge.
Able to lift up to 50 pounds occasionally to assist with patient transfers; lifting over 50 pounds must be performed with team lifts.
Able to push and pull up to 25 pounds of horizontal force occasionally and up to 40 pounds rarely.
Ability to administer CPR.

Nice To Haves

Three to five years of relevant experience.

Responsibilities

Prepare patient progress notes in EPIC using provider-built documentation tools, including history of present illness, review of systems, physical exam, assessment, and plan.
Ensure the health maintenance section, including quality reporting measures and immunizations, is up to date.
Room and prepare patients for examination by reviewing histories, allergies, medications, and reason for visit, and taking vital signs.
Under provider standing orders, order or administer injections, order or collect laboratory specimens, perform phlebotomy as needed, and provide test results as directed.
Enter patient-reported information into provider-built EPIC tools for disease-state and preventive visits.
Communicate a summary of patient-reported information to the provider before or during the patient visit.
Document patient encounters in real time, including relevant histories, examinations, assessments, plans, procedures, treatments, education, orders, medications, referrals, risk-benefit explanations, and follow-up instructions.
Identify documentation completed on behalf of a provider using the scribe signature in accordance with policy.
Provide patient instructions using approved education materials, as directed by the provider.
Print the after-visit summary and discharge patients, including scheduling follow-up appointments, providing referral information, and arranging tests and instructions as needed.
Manage calls to patients about test or laboratory results and provide treatment instructions as directed by the provider.
Process medication requests, changes, and refills under established written protocols, applying knowledge of medications, basic dosages, side effects, and interactions.
Assist with diagnostic procedures and treatments, including EKGs and nebulizer treatments, and obtain, label, and deliver specimens to the laboratory.
Explain diagnostic procedures to patients as needed.
Prepare exam and treatment rooms with instruments, supplies, and protective devices.
Perform other duties as assigned.
Follow Mercy safety guidelines and job-specific safety responsibilities, and promptly report unsafe conditions, situations, incidents, and injuries.