Nurse-(CCMA or LPN) - Clinical Scribe

Essential Functions:

• Records details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications and allergies as directed by physician.
• Record details of physical exam, including pertinent positives and negatives, noted abnormalities and patient general condition as directed by physician.
• Submit orders as desired by physician and check constantly for results of those orders.
• Responsible for troubleshooting for causes and solutions to any delays regarding the aforementioned orders.
• Must be knowledgeable of EMR.
• Assist in disposition of patient including prescriptions.
• Responsible for other nursing job duties as assigned.
• Attends meetings as required.

Skills/Abilities:

• Working knowledge of medical terminology and accepted abbreviations.
• Recognition of physical exam process and ability to record exam details.
• Must be proficient on the computer and have ability to ACCURATELY record information.
• Knowledge of all aspects of medication names and prescribing.
• Knowledge of policies and procedures related to infection control, environmental safety and patient confidentiality as directed by HIPAA standards.
• Knowledge of medical chart reporting and records.
• Knowledge of clinic/medical practice procedures related to all medical operations.
• Must have good computer skills.
• Must be skilled in customer service and have a pleasant and courteous demeanor while dealing with patients.
• Must have skills in critical thinking, communication, influence and decision making.
• Must have the ability to work cooperatively as a member of office staff and team.

Mental/Physical Requirements:

• Some lifting and carrying up to 10 pounds.
• Sedentary 6-7 hours/day.  
• Can suffer wrist, back, neck, or eye problems due to strain and risk repetitive motion injuries such as carpal tunnel syndrome.
• Constant pressure to be accurate and productive can be stressful.

Qualifications:

Education:   

High School Diploma or equivalent

Licenses and Certifications

Certified Medical Assistant Certification or LPN License