Mercy Cedar Rapids·Baltimore, Maryland
The Clinical Scribe will prepare patient visit documentation, assist with patient examinations, and ensure accurate recording of patient encounters. Additionally, the role involves coordinating surgery schedules and providing patient education.
Join our growing Neurosurgery Clinic team and play a vital role in guiding patients through some of the most important moments of their care. You’ll work closely with surgeons and clinic staff to ensure seamless, high-quality care for patients through education and surgery coordination. If you’re a compassionate, detail-oriented nurse who is passionate about patient centered care, we’d love to welcome you to our team.
Scheduled Weekly Hours: 0
This position supports Mercy's philosophy of patient centered care by presenting excellent customer service and enables the facilitation of positive patient outcomes by providing nursing support to a Mercy provider.
Job Duties
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.
Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.
• Excellent communication and customer service skills, computer skills, organization, time management, attention to detail and the ability to remain poised and efficient in a fast-paced environment.
Mercy is an independent, community-based organization supporting the Cedar Rapids area for over 120 years.
Mercy is an equal-opportunity employer. We value diversity, equity, and inclusion and therefore evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status, and other legally protected characteristics.
Candidates must have education sufficient to obtain RN licensure or be a CMA, along with current Basic Life Support certification. Previous experience in a medical office setting is preferred.
Market context
In Maryland, nursing openings that require an RN and outpatient care experience are typically competitive because employers often want candidates who can step into ambulatory workflows with limited onboarding. Strong applicants usually show familiarity with patient education, care coordination, and fast-paced clinic settings. Review the AI-summarized requirements and benefits on this page to save time, then compare your outpatient experience to the core duties before applying.