Scribe

POSITION SUMMARY: The Medical Scribe supports providers by accurately and efficiently documenting patient encounters in real time during clinical visits. This role allows providers to focus on patient care while ensuring complete and compliant medical records.

KEY RESPONSIBILITIES:

• Document patient histories, physical exams, procedures, diagnoses, treatment plans, and follow-up instructions as dictated by the provider during the visit.
• Enter orders for diagnostic tests, prescriptions, and referrals as directed by the provider.
• Ensure that all patient documentation meets legal, ethical, and compliance requirements.
• Retrieve prior medical records, imaging results, and other relevant patient information for provider review.
• Maintain strict patient confidentiality in accordance with HIPAA regulations.
• Assist providers in navigating the electronic medical record (EMR) and locating appropriate reference information.
• Schedule and order imaging, diagnostic tests and surgeries as required.
• Educate patients on wound care, brace use, and follow-up instructions.
• Answer patient questions via phone or in person in a timely and professional manner.
• Assist Medical Assistant as needed in maintaining a clean and stocked exam room, handle biohazardous waste in compliance with safety standards.
• Perform additional duties as assigned by the supervising physician.

REQUIRED SKILLS & COMPETENCIES:

• Excellent typing and data entry skills with a high level of accuracy.
• Strong listening and comprehension skills.
• Working knowledge of medical terminology, anatomy, and clinical procedures.
• Ability to multitask in a fast-paced environment.
• Strong attention to detail and accuracy.
• Commitment to maintaining patient confidentiality
• Excellent verbal and written communication skills.

MINIMUM QUALIFICATIONS:

• High school diploma or equivalent; college coursework in health sciences preferred.
• Prior experience as a scribe, medical assistant, or in a healthcare setting preferred.
• Proficiency in electronic medical records (EMR) systems.

WORK ENVIRONMENT: This position operates in a clinical setting, often in close proximity to patients and providers. The role may involve exposure to bodily fluids and infectious diseases. Personal protective equipment (PPE) is provided and required as appropriate.

PHYSICAL DEMANDS: The employee is regularly required to sit, type, and use a computer for extended periods. The employee may occasionally be required to stand, walk, and lift up to 20 pounds. Visual acuity and hearing ability are essential to perform job functions accurately.