Clinical Scribe - CMA/LPN/RN - Neurosurgery Clinic -Mercy Medical Center - Cedar Rapids

• 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.

• Prepares instruments, supplies and protective devices for exam and testing prior to the visit.
• 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.
• 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.
• Manages sample medication according to organizational policy and procedure.
• Orders and maintains adequate but not excessive medical supply inventory.
• Collects and documents urine drug screens in compliance with regulations.
• 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.
• 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.

Knowledge, Skills and Abilities

• General knowledge and understanding of anatomy, the diagnosis process, pharmacology (drug classifications, side effects, interactions) physiology, lab values, sterilization techniques and safe administration of medications.
• Operational knowledge of neurosurgical conditions, cranial tumors and their treatments.
• Basic computer knowledge and navigation of an E.H.R.

• Required: Successfully completed clinic transformation with assigned provider to include scribe training or go-live support; or hired directly into a provider area that has already implemented clinic transformation. The CMA will be trained as a Clinical Scribe immediately upon hire.

• Preferred: One year experience in a medical office.

• Graduate of an accredited medical assistant program or sufficient education to obtain RN or LPN  license. 

• Medical Assistant Certification required or LPN/RN license required. Must be able to practice in the state of Iowa. 
• Current certification in Basic Life Support (BLS), in accordance with the American Heart Association required.
• Iowa Dependent Adult Abuse & Iowa Child Abuse Mandatory Reporter training required.  Employee must submit certification of completed training to Human Resources prior to start or transfer date.

• Medium:
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    • 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