Medical Scribe

## Description

Job Description

The Medical Scribe supports physicians and advanced practice providers by accurately documenting patient encounters in the electronic health record. This role allows providers to focus more directly on patient care while ensuring documentation is complete, accurate, and entered in a timely manner.

The Medical Scribe must maintain patient confidentiality, demonstrate strong attention to detail, and work effectively in a fast-paced clinical environment.

Responsibilities

• Accompany the provider during patient visits and document the encounter in real time.
• Record the patient’s history, symptoms, physical examination findings, diagnoses, treatment plans, medications, and follow-up instructions as directed by the provider.
• Update patient charts in the electronic health record.
• Enter orders, referrals, prescriptions, and diagnostic testing requests for provider review and approval.
• Prepare charts before patient appointments by reviewing relevant medical history, test results, and previous documentation.
• Assist providers with locating laboratory results, imaging reports, consultation notes, and other clinical information.
• Ensure documentation is accurate, complete, and ready for the provider’s review and signature.
• Communicate documentation questions or missing information to the provider.
• Follow all HIPAA requirements and maintain strict patient confidentiality.
• Work collaboratively with providers, medical assistants, front desk employees, surgical schedulers, and other clinical team members.
• Perform other administrative or clinical documentation duties as assigned.

## Qualifications

Qualifications

• High school diploma or equivalent required.
• Associate’s or bachelor’s degree in healthcare, biology, pre-medical studies, or a related field preferred.
• Previous medical scribe, medical assistant, or clinical documentation experience on eClinicalWorks preferred.
• Knowledge of medical terminology, anatomy, and common clinical procedures preferred.
• Knowledge of eCW.
• Experience using an electronic health record system is preferred.
• Strong typing, spelling, grammar, and organizational skills.
• Ability to listen, document, and communicate accurately in a fast-paced environment.
• Ability to maintain professionalism and confidentiality.
• Strong attention to detail and the ability to manage multiple priorities.

Physical and Scheduling Requirements

• Ability to sit, stand, and move throughout the clinical office for extended periods.
• Ability to work alongside providers during scheduled patient sessions.
• Flexibility to travel between practice locations may be required.
• Occasional evening or extended hours may be required based on provider schedules.

Important Role Limitations

The Medical Scribe does not provide independent medical advice, diagnose patients, make treatment decisions, or perform duties outside the individual’s training and authorized scope. All documentation, orders, and clinical information must be reviewed and approved by the treating provider.