This great career opportunity is located at our Grandview clinic location.
This Registered Nurse will serve as a Medical Scribe to a physician in clinic. The primary role of a Medical Scribe is to increase the efficiency and the productivity of the physician by performing clerical and information technology functions. Accompanies the physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present. Other tasks include obtaining medical records from other facilities and scheduling consults.
Provides professional nursing care for patients following established standards and practices in an Oncology Clinic setting. Demonstrates knowledge of differences in the patient population which includes late adolescence, adulthood, middle age, and elderly .
Essential Duties and Responsibilities:
- Transcribe physician’s note as physician is speaking with patients by documenting History of Present Illness, Family and Social History, Review of Systems, and Physical Exam as dictated by the provider.
- Review documents for mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors.
- Establish and maintain effective working relationships with physicians, staff, and management.
- Enter tests and procedures as ordered by physician.
- Operate electronic medical records.
- Adhere to employer work practices.
- Assists physician with exams and procedures. Maintains appropriate and efficient patient flow in and out of exam rooms.
- Records patient data including, but not limited to, vital signs, height, weight, allergies, medication changes, etc.
- Maintains disinfection protocols
- Monitors and assesses changes in patient conditions and initiates appropriates actions.
- Facilitates dose modification
- Assesses patients for changes in condition, including but not limited to abnormal labs, x-rays, scans, drug reactions
and initiates appropriate actions. - Maintains knowledge of reimbursement procedures. Completes all chemotherapy charge forms. Assures preauthorization and appropriate consent forms are obtained prior to administration of therapies.
- Demonstrates knowledge of ambulatory infusion pump use and maintenance, cleaning pumps after use, and proper documentation of pump usage.
- Facilitates dose modification by assessing patient, assessing labs, consulting protocol or treatment plan, calculating
dose, and consulting physician regarding dosage modifications, problems, and symptom management. - Performs venipuncture, accesses implanted ports and maintains central lines catheter devices.
- Administers all medications/blood products using correct medication/blood product, dosage/amount, route, time
and technique. - Displays appropriate technical skills for the administration of chemotherapy, medications and blood products, to
include, but not limited to: venipuncture, central line access and infusion devices. - Programs portable infusion pumps for continuous drug delivery and provides instruction to the patient and/or caregiver in the use of the pump at home.
- Documents nursing assessments, patient teaching and fluid and medication administration in the patient chart.
- Communicates all pertinent information and any interventions to the physician.
- Assures nursing charges are accurate and complete on patient fee slips.
- Acts as a resource person to the medical assistants.
- Triages patient phone calls as needed and documents relevant information in the patient's chart.
- All other duties as assigned.
Requirements
- Graduate from accredited for professional nursing education, BSN preferred.
- Minimum of one (1) year nursing experience, preferably in a an oncology environment.
- RN state license and current registration with the State Board of Nursing.
Additional Skills and Abilities:
- Strong attention to detail
- Excellent computer skills
- Must comply with HIPAA confidentiality standards.
- Ability to communicate effectively in the English language in person, by phone and in writing