Medical Scribe acts as an assistant during the examination and treatment of patients under the direction of a physician. Documents and gathers information during the treatment process. Being a Medical Scribe organizes healthcare data to provide better service and efficiency of clinical care. Typically requires an associate degree. Additionally, Medical Scribe may require certification as a Medical Scribe by the American College of Clinical Information Managers (ACCIM). Typically reports to a physician. The Medical Scribe works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be a Medical Scribe typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
Description
Position Summary
Works to facilitate patient flow and ensure an accurate and complete medical record for each patient.
Primary Responsibilities
Reasonable accommodations may be made to enable individuals with disabilities to perform the primary responsibilities.
1. Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present.
2. List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
3. Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
4. Document any procedures performed by the physician.
5. Maintain professional appearance and conduct at all times.
6. Adhere to employer work practices.
7. Establish and maintain effective working relationships with physicians, staff and managements.
8. Effectively cope with typical job stress.
9. Document work processes as required.
10. Perform other duties as assigned.
Competencies
1. Medical terminology.
2. Recognition of physical exam process and ability to record exam details.
3. Computer proficiency and ability to quickly learn new applications.
4. Ability to type 65 Words per Minute and ability to accurately record information.
5. Organizational skills with focus on tracking patient care and improving patient flow.
6. Professional demeanor and recognition of privacy considerations for patients and families.
7. Ability to use appropriate discretion in handling confidential information and materials.
Supervisory Responsibility
None.
Requirements
Required Education and Experience
1. Bachelor of Science degree is preferred, but not required.
2. Graduation from an AMA-approved school of Radiologic Technology required.
3. Registered with the American Registry of Radiologic Technologists required.
4. Current LSRT State license – required.
5. Current BCLS certification required.
Preferred Education and Experience
1. High school diploma or equivalent.
2. 6 months experience as a Medical Scribe or 6 months related experience and/or training, or equivalent combination of education and experience.
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