Medical Scribe

Job Summary:

The primary responsibility of a medical scribe is documenting and charting medical data discussed during provider-patient encounters. The scribe follows the provider into patient rooms, and serves as the documentor of relevant notes and medical data that traditionally would be recorded by the provider. The Medical Scribe increases the efficiency and the productivity of the physician they are working for by relieving the physician of the burden of taking the notes and documenting themselves allowing their primary focus to be on the patient.

Essential Job Functions:

• Scribes document the entire patient encounter from start to finish; including the patient's history, physician exam, provider orders, patient outcomes, labs, imaging and more.
• Scribes will assist in the organization of patient information in the electronic medical record (EMR) prior to each patient encounter, allowing providers to move more efficiently between patient visits.

• Each patient will have a unique medical history and an existing medical record. The medical scribe will input these records into their system’s Electronic Medical Record (EMR).
• History of Present Illness (HPI) is a concise narrative of the patient’s story that includes the context of their chief complaint, past medical history, symptoms, that the medical scribe is creating. The scribe writes an HPI based on the observed provider and patient interaction.
• During the patient encounter, the patient will answer questions from the physician about symptoms, exercise, diet, which the medical scribe will document. Also, medical tests that are conducted such as basic vitals or imaging studies will also need to be documented by the medical scribe.
• The scribe will document procedures and treatments performed by healthcare professionals, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
• Sometimes physicians will speak notes about the visit and/or their medical decision making into a dictaphone, scribes will listen to these dictations and translate the information into the EMR.
• Scribes will sometimes write referral letters for doctors or other types of correspondence.
• Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. Any changes or corrections must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.
• Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Qualifications:

• Proficient in typing, spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production.
• Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.
• Must be able to learn and use all functions of electronic medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email and attachments.
• Must be able to type words and numbers quickly and accurately.
• Must comply with HIPAA confidentiality standards when accessing or communicating patient information.
• Good judgment, organizational ability, initiative, attention to detail.
• Good attendance is required.

Physical Demands:

Must be able to sit for long periods of time, and must have manual dexterity to work computer systems and keyboard. It is reasonable to anticipate lifting 10 -15 pounds in any given day.