Medical Scribe

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.