Clinical Scribe - Rn/Lpn

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.

N/A

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

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 sufficient to obtain required licensure

Required: Registered Nurse/LPN License 

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.

Work requires close vision, distance vision, depth perception and ability to adjust focus.

Ability to read pertinent printed material and distinguish colors.

Ability to include inspection during patient assessment.

Ability to accurately read measurements on patient related equipment—some examples include: thermometers, mechanical gauges, glucometers, IV pumps, and computer monitor displays.

Worker must be able to visually assess patients’ safety needs.

Normal visual acuity required to maintain accuracy and neatness of work.

Preparing and reading written documentation, use of computer.

Peripheral vision.

Adaptability to performing under stress when confronted with emergent, critical, unusual, or dangerous situations, or situation in which working speed and sustained attention are make-or-break aspects of the job.

Adaptability to performing a variety of duties, often changing from one task to another without loss of efficiency or composure.

Ability to maintain both a high standard of courtesy and cooperation in dealing with co-workers, patients and visitors and satisfactory job performance despite the stress of a hospital work environment.

Demonstrates knowledge and skills necessary to interact with patient populations; e.g.infant, pediatric, adolescent, adult and geriatric.

Ability to perform under stress when confronted with emergency, critical, or unusual situations.

Ability to make generalizations, evaluations or decisions based on measurable or verifiable criteria; e.g. patient assessment and/or equipment performance.

Adaptability to performing repetitive work or to performing continuously the same work, according to set procedures sequence or pace.

Adaptability to dealing with people beyond giving and receiving instructions.

Able to communicate with people regarding giving and receiving of instructions.

Adaptability to changing priorities.