Position Purpose:

Medical Scribes are individuals trained in medical documentation who assist a medical provider throughout their shift. The primary purpose of a Medical Scribe is to increase the efficiency and productivity of the Provider they are working for.

Essential Functions and Basic Duties:

• Support and report directly to the assigned provider;
• Perform all clerical and information technology functions for a provider in the office setting including but not limited to:
  • Operation of the electronic health record (EHR) systems;
  • Documentation of all communication (verbal/written) within the appropriate patient’s health record;
• Anticipate the needs of the assigned provider to facilitate efficient patient flow;
• Maintain the highest level of confidentiality with information that may be discussed throughout an examination;
• Remain discreet, tactful, and modest in the performance of duties so as not to distract the provider from patient care;
• Exercise good judgment, organizational ability, initiative, attention to detail, and the ability to be adaptable and self-motivated.

General Description:

• Accurately and thoroughly document medical visits and procedures as they are being performed by the provider, including but not limited to:
  • Patient medical history and physical exam;
  • Procedures and treatments performed by all clinical staff including providers and support staff;
  • Patient education and explanations of risks and benefits;
  • Physician-dictated diagnoses, prescriptions, and instructions for patient or family members for self-care and follow-up;
  • Prepare referral letters as directed by the provider.
• Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the provider, via dictation or summary of the medical record. You may be asked to research contact information for referring physicians, coordinate referrals, prepare reports, make phone calls, and other clerical tasks as assigned.
• Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. Any addenda must be signed off by a provider.
• Medical Scribes will alert the provider when a chart is incomplete and will ensure compliance with finalizing all notes within 48 hours of the visit.
• Medical Scribes ensure that all clinical data, lab or other test results, and the interpretation of the results by the provider are recorded accurately in the medical record. Medical Scribes must comply with specific standards that apply to medical records and with the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
• Medical Scribes collect, organize and catalog data for provider quality reporting systems and other quality improvement efforts and format for submission.
• Attend training on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing, and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the provider’s medical documents for accuracy, spelling, punctuation, and grammar.
• Other duties as assigned by the provider or office management.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Language Skills – The ability to write routine reports and correspondence. Medical Scribes must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize it in a clear, complete, and concise fashion. Excellent English composition skills are required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.
• Prior Knowledge - Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms. Prior related work experience is preferred.
• Mathematical Skills – Ability to add, subtract, multiply, and divide into all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.
• Reasoning Ability – Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.
• Computer Skills – To perform this job successfully, an individual should be able to learn and use all functions of electronic health record software. Must accurately enter data into a database, search for information, and send and receive emails and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.
• Physical Demands – While performing the duties of this job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception, and the ability to adjust focus.
• Attendance - Due to the critical nature of this position, a Medical Scribe must have a proven track record of excellent attendance including arriving on time for work and not missing scheduled days of work. Overtime may be required and/or hours may be shortened as business needs dictate.
• Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information. Ability to work in an environment with exposure to potentially dangerous/infectious materials and situations that require following extensive safety precautions that may include the use of personal protective equipment (PPE).
• Education – High School Diploma/GED required. An undergraduate degree or College level coursework in a related field is preferred.

The above duties and responsibilities are intended to describe the general nature and level of work being performed by people assigned to this position. They are not intended to be an exhaustive list of responsibilities, duties, and skills required of persons so assigned.