Job Summary

The Medical Scribe works closely with a physician to provide accurate, timely documentation of patient encounters in the electronic medical record. The Medical Scribe accompanies the physician during patient visits, documents the encounter as directed, and helps ensure the medical record accurately reflects the care provided.

This position requires excellent attention to detail, strong communication and organizational skills, an understanding of medical terminology, and the ability to work efficiently in a busy clinical environment.

Primary Responsibilities

• Accompany the physician during patient interviews, examinations, and other patient care activities.
• Document patient encounters in the electronic medical record as directed by the physician, including history of present illness, review of systems, past medical and surgical history, family and social history, medications, and allergies.
• Document physical examination findings, procedures, diagnoses, treatment plans, and other elements of the encounter as directed by the physician.
• Document laboratory, imaging, and other diagnostic results as reviewed and communicated by the physician.
• Accurately document relevant patient care activities and communications, including discussions with other healthcare providers, patients, and family members when appropriate.
• Prepare and maintain accurate, complete, and timely medical records for physician review and approval.
• Assist the physician with documentation workflow throughout the clinic day.
• Maintain an understanding of the team approach to patient care and work collaboratively with physicians, clinical staff, and other team members.
• Maintain patient confidentiality and comply with HIPAA and all applicable documentation requirements.
• Communicate professionally and respectfully with physicians, team members, patients, and others encountered in the clinical setting.
• Perform other duties as assigned.

 Education and Experience

• High school diploma or GED required.
• Previous medical scribe experience preferred.
• Previous experience in a medical office or clinical setting preferred.
• Knowledge of basic medical terminology preferred.
• Experience working with an electronic medical record system preferred.

Knowledge, Skills, and Abilities

• The successful candidate should demonstrate:
• Knowledge of medical terminology and basic medical office procedures.
• Excellent grammar, spelling, punctuation, and written communication skills.
• Strong attention to detail and commitment to accurate documentation.
• Ability to type efficiently and accurately while following a patient encounter.
• Strong organizational, time management, prioritization, and multitasking skills.
• Ability to work efficiently in a fast-paced clinical environment.
• Ability to learn and use electronic medical record systems and other computer applications.
• Ability to understand and follow verbal and written instructions.
• Ability to communicate clearly and professionally.
• Ability to establish and maintain effective working relationships with physicians, patients, clinical staff, and other team members.
• Ability to maintain confidentiality and protect patient information in accordance with HIPAA and other applicable requirements.
• Ability to recognize when clarification is needed and communicate appropriately with the supervising physician.

Work Environment

Work is performed primarily in a medical office and clinical environment with frequent interaction with physicians, clinical staff, and patients. The position requires the ability to work effectively in a busy environment while maintaining accuracy, professionalism, and attention to detail.
Physical Requirements

The position requires the ability to perform the physical activities normally associated with a Medical Scribe, including operating a computer and other office equipment and sitting, standing, walking, bending, and reaching as needed. The Medical Scribe may be required to stand or walk for extended periods while accompanying the physician during patient care.