Medical Scribe

About the role

Medical scribes specialize in documenting doctor-patient encounters in real-time. They are responsible for accurately recording clinical notes for the Providers and also perform other tasks such as patient calls, referrals, and clerical work. Additionally, they help doctors locate patient information and complete necessary forms for patient care. Their role helps improve the accuracy and efficiency of recording medical histories in various healthcare facilities. Virtual medical scribes enable doctors to concentrate more on their patients, thus resulting in better patient satisfaction. They are an extension of the healthcare providers' medical back-office team and provide clinical documentation support.

Key responsibilities

• Preparing the electronic charts for new and established patients by entering referring and other treating Provider(s) contact information and all historical and current medical information relevant to the office visit, including patient history, symptoms, and complaints.
• Transcribing medical data quickly and accurately while patients are being examined.
• Maintain records consistently using accurate spelling, correct grammar, and complete notes.
• Recording chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications, and allergies information obtained directly from a medical provider.
• Record details of a physical exam, including pertinent positives and negatives, noted abnormalities, and patient's general condition obtained directly from medical providers.
• Submit orders as instructed by the medical providers and monitor the results of those orders.
• Record necessary documentation on all EHR tabs and re-verify information on each visit, such as medication reconciliation, review of drug allergies, etc.
• Ensuring medical record compliance by self-documentation attestation to include Scribe name, title, and medical provider working for as well as specific date and time entry.
• Maintain confidentiality in accordance with HIPAA laws and regulations, per practice policy.
• Support and/or provide backup for back-office staff.

About you

• Excellent oral communication skills
• Medical terminology knowledge
• Administrative written skills
• Human anatomy knowledge
• Microsoft Office skills
• Customer relations
• Confidentiality and computer literacy
• Typing skills: Minimum of 55 wpm required
• Proven work experience as a Medical Scribe or similar role recording a medical provider's interaction with patients
• Ability to read, write, comprehend through listening, and speak fluent English