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)
JOB TITLE: Medical Scribe
GENERAL SUMMARY OF DUTIES:
The Medical Scribe accompanies a 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. Lists all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. Transcribes patient orders including laboratory tests, radiology tests, medications, etc. Documents any procedures performed by the physician. Strong Medical terminology is a must and recognition of physical exam process and ability to record exam details.
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