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.
- 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- a Scribe does no medical decision-making.
- Record details of a physical exam, including pertinent positives and negatives, noted abnormalities, and patient’s general condition obtained directly from medical providers- Scribe does no medical decision-making.
- Submit orders as instructed by the medical providers and monitor the results of those orders. Inform medical providers that results are ready to be reviewed- Scribe does no medical decision-making.
- 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.
- Preparing and sending all documentation to medical providers for review and approval using the EHR-approved authentication process.
- Ensure the patient's chart and encounter contains all pertinent information necessary for the visit or with any patient interaction. This should be done through tasks, messages, or charted in patient chart notes.
- Make sure the Health Maintenance Tab is reviewed and completed, if necessary, on every patient.
- Understand and make sure that all required back office processes are being done for each medical provider to meet Macra/MIPS requirements per the practice guidelines for every patient.
- Maintain confidentiality in accordance with HIPAA laws and regulations, per practice policy.
- Perform other related duties as assigned and follow all company policies outlined by practice.
- Support and/or provide backup for back-office staff. This includes inputting and/or re-verifying all the required documentation on all EHR tabs before the treating provider sees the patient.
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
- The requirements listed below represent the knowledge, skills, and/or ability required. Reasonable
- accommodations may be made to enable individuals with disabilities to perform essential functions.
Skills
- Excellent Oral Communication Skills Medical Terminology
- Administrative Written Skills Human Anatomy Knowledge
- Microsoft Office Skills Customer Relations
- Confidentiality and Computer Literacy
- Customer Service Professionalism
- Interpersonal Communication Skills Reading Skills
- Diplomacy and Time Management
- Typing Skills: Minimum of 55 wpm required Reporting Skills
- Organizational Skills
Education/Training
- Bachelor’s degree with pre-health career track, preferred
- Skilled in various medical software and hardware, word processing, and EHR systems)
Experience
- Proven work experience as a Medical Scribe or similar role recording a medical provider’s interaction with patients.
Physical Demands
The physical demands described here must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee is regularly required to
- Ability to view computer monitors with close vision, color vision, depth perception, and ability to adjust your focus with good hand-eye coordination
- Ability to work in a fast-paced environment
- Ability to read, write, comprehend through listening, and speak fluent English
