Medical Scribe

Medical Scribe – OB/GYN Job Description Job Title

Medical Scribe – Obstetrics & Gynecology (OB/GYN)

Department

Clinical Operations

Reports To

Physician, Nurse Practitioner, Physician Assistant, or Clinical Manager

Position Summary

The Medical Scribe is responsible for accurately documenting patient encounters in real time during office visits, prenatal appointments, gynecologic examinations, and procedures. Working alongside the provider, the Medical Scribe ensures complete and timely documentation in the electronic medical record (EMR), allowing the provider to focus on delivering exceptional patient care while maintaining accurate medical records.

Essential Duties and Responsibilities

• Document patient encounters in the electronic medical record (EMR) during office visits, including:
• Chief complaint
• History of present illness (HPI)
• Review of systems (ROS)
• Past medical, surgical, family, and social history
• Physical examination findings
• Assessment and treatment plans
• Accurately document prenatal visits, including gestational age, fetal heart tones, fundal height, patient concerns, and provider recommendations.
• Document gynecologic examinations, annual well-woman exams, contraceptive counseling, menopause management, and follow-up visits.
• Record findings from procedures such as:
• Colposcopies
• Endometrial biopsies
• IUD insertions and removals
• Nexplanon insertions and removals
• Cervical biopsies
• Office ultrasounds (as directed)
• Prepare patient charts before appointments by reviewing previous notes, laboratory results, imaging, pathology reports, and outstanding follow-up items.
• Enter physician-directed orders for laboratory tests, imaging, referrals, and prescriptions in accordance with clinic policy and provider authorization.
• Document telephone encounters, patient portal communications, and follow-up instructions as assigned.
• Assist with referral documentation and coordination of patient care.
• Ensure documentation is complete, accurate, and finalized promptly.
• Maintain strict patient confidentiality in accordance with HIPAA regulations.
• Communicate professionally with physicians, advanced practice providers, nurses, medical assistants, laboratory personnel, and front office staff.
• Perform additional administrative duties as assigned.

Qualifications

• High school diploma or equivalent required.
• Associate's or Bachelor's degree in a healthcare-related field preferred.
• Previous experience as a Medical Scribe, Medical Assistant, or healthcare professional preferred.
• Experience in an OB/GYN or Women's Health practice is highly desirable.
• Strong knowledge of medical terminology, anatomy, and physiology.
• Familiarity with obstetric and gynecologic terminology preferred.
• Experience using Electronic Medical Record (EMR) systems.
• Excellent typing and computer skills.
• Strong grammar, spelling, and written communication skills.
• Ability to work efficiently in a fast-paced clinical environment.

Knowledge, Skills, and Abilities

• Knowledge of women's health, obstetrics, and gynecology terminology.
• Ability to document physician-patient encounters accurately and efficiently.
• Understanding of prenatal care schedules and common obstetric conditions.
• Familiarity with gynecologic procedures and documentation requirements.
• Excellent attention to detail and organizational skills.
• Strong listening, communication, and interpersonal skills.
• Ability to multitask while maintaining documentation accuracy.
• Ability to maintain professionalism, discretion, and patient confidentiality.

Physical Requirements

• Ability to sit, stand, and walk for extended periods.
• Frequent use of computers, keyboards, and office equipment.
• Ability to move between exam rooms throughout the workday.
• Occasional lifting of up to 20 pounds.

Work Environment

• Outpatient OB/GYN clinic or women's health practice.
• Frequent interaction with patients, physicians, nurses, medical assistants, and administrative staff.
• Fast-paced environment requiring attention to detail, professionalism, and excellent time management.

Preferred Experience

Candidates with experience documenting the following are strongly preferred:

• Prenatal and postpartum care
• High-risk obstetric visits
• Annual well-woman examinations
• Family planning and contraceptive counseling
• Infertility evaluations
• Menopause management
• Abnormal Pap smear follow-up
• Colposcopy procedures
• Pelvic ultrasound documentation
• Electronic Fetal Monitoring terminology (preferred but not required)

Performance Expectations

• Produce timely, accurate, and complete medical documentation.
• Demonstrate knowledge of OB/GYN terminology and clinical workflows.
• Maintain compliance with HIPAA and clinic policies.
• Exhibit professionalism and compassion when interacting with patients and staff.
• Consistently meet productivity and documentation quality standards.
• Maintain dependable attendance and punctuality.
• Support providers in delivering efficient, high-quality patient care.

Pay: $21.00 - $24.00 per hour

Benefits:

• 401(k)

Experience:

• medical scribing: 1 year (Preferred)

Work Location: In person

Salary : $21 - $24