Medical Scribes are individuals trained in medical documentation who assist a physician throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient.
A summary of a Medical Scribes duties include performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. You also must be able anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. You must be adaptable and versatile since you will be responsible for many tasks. Good attendance is also an important element of this job since you will be hard to replace.
Some of the more detailed job duties and responsibilities of a Medical Scribe are:
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
- Patient medical history and physical exam,
- Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
- 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 physician
Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative 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. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.
Attend trainings 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 physician’s medical documents for accuracy, spelling, punctuation, and grammar.
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 the 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 in a clear, complete, and concise fashion. Excellent English composition skills required to generate professional, polished writing at a high rate of production. Handwriting must be clear and legible.
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.
Mathematical Skills – Ability to add, subtract, multiply, and divide in 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 medical record software and transcription software. Must accurately enter data into a database, search for information, send and receive email 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.
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.