Job Description

Job Summary

The Medical Scribe is responsible for documenting patient encounters and assisting healthcare providers by accurately recording medical histories, examination findings, treatment plans, and other relevant information during patient visits. This role ensures that medical records are complete, accurate, and compliant with regulatory standards, allowing healthcare providers to focus on patient care and improving clinical efficiency.

Essential Functions

• Provides support to physicians and healthcare providers by documenting medical information, reducing their clerical workload.
• Accurately and efficiently documents patient histories, physical exams, diagnoses, treatment plans, and other relevant information during patient visits in real-time.
• Identifies and clarifies inconsistencies, discrepancies, and inaccuracies in medical dictation, editing as necessary to ensure accuracy without altering the provider's intent.
• Records all physician-patient interactions, including medical notes, lab results, medications, and follow-up instructions, in the electronic health record (EHR) system.
• Maintains up-to-date and organizes patient records in the EHR system, ensuring proper coding, compliance with regulations, and proper documentation practices.
• Reviews and updates patient charts before the physician enters the room for patient encounters to ensure all relevant information is present.
• Relays important information between patients and healthcare providers, as well as coordinate communication with other healthcare professionals as needed.
• Adheres to healthcare regulations, including HIPAA, to maintain the confidentiality and privacy of patient information.
• Documents lab results, imaging studies, and diagnostic tests in patient records promptly.
• Reviews patient charts and documentation for accuracy, completeness, proper formatting, and flag any missing or incomplete information for follow-up and correction.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Coursework in medical terminology, anatomy, or healthcare documentation preferred
• 0-2 years of experience in a healthcare setting with experience in medical scribing or healthcare documentation preferred

Knowledge, Skills and Abilities

• Proficient knowledge of medical terminology and human anatomy.
• Strong attention to detail and accuracy in documentation.
• Excellent written and verbal communication skills to facilitate effective documentation.
• Ability to manage time effectively and work efficiently in a fast-paced clinical environment.
• Basic computer skills, including familiarity with EHR or healthcare documentation software.

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