About This Role
This role involves documenting doctor-patient encounters in real-time, accurately recording clinical notes for providers, and performing various administrative tasks. Medical scribes help improve the accuracy and efficiency of medical history recording in healthcare settings, allowing doctors to focus more on patient care.
Responsibilities
- Prepare electronic charts for new and established patients by entering referring and other treating provider(s) contact information and all relevant historical and current medical information, including patient history, symptoms, and complaints
- Transcribe medical data quickly and accurately during patient examinations
- Maintain consistent records using accurate spelling, correct grammar, and complete notes
- Record 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 the patient's general condition obtained directly from medical providers
- Submit orders as instructed by 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.
- Ensure 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
Requirements
- 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