GENERAL SUMMARY OF DUTIES: Performs all clerical and
information technology functions in a clinic setting at the time of the office
visit to increase the physician's efficiency and productivity. Maintains primary responsibility of the
operation of electronic health records.
SUPERVISION REQUIRED: Reports to office manager and/or
SUPERVISION EXERCISED: This position does not supervise any
1. Accurately and
thoroughly document medical visits and procedures as they are being performed
by the physician, including but not limited to:
Patient medical history and physical
Procedures and treatments performed
by healthcare professionals, including nurses and physician assistants.
Patient education and explanations
of risks and benefits.
prescriptions and instructions for patient or family members for self-care and
Prepare referral letters as directed
by the physician
Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to
prepare referral letters as directed by the physician, via dictation or summary
of the medical record. Medical Scribe also ensures that letters are mailed or
faxed on a daily basis to all physicians involved in a patient's care, and with
all copies of pertinent reports or tests attached. May be asked to research
contact information for referring physicians, coordinate referrals, prepare
operative reports, make phone calls, and other clerical tasks as assigned.
Scribes also spot mistakes or inconsistencies in medical documentation and
check to correct the information in order to reduce errors. All addenda
must be signed off by a physician. Medical Scribes ensure that all clinical
data, lab or other test results, the interpretation of the results by the
physician are recorded accurately in the medical record. Alert physician
when chart is incomplete. Medical Scribes must comply with specific standards
that apply to the style of medical records and to the legal and ethical
requirements for preparing medical documents and for keeping patient
Scribes proofread and edit all the physician's medical documents for accuracy,
spelling, punctuation, and grammar.
EXPERIENCE: Previous medical office experience
required. EMR experience preferred.
Skills – The ability to write routine reports and correspondence. Medical
Scribes must be proficient in typing and good at spelling, punctuation,
grammar, and oral communication. Must be able to listen to complex medical
information and summarize in a clear, complete, and concise fashion. Excellent
English composition skills required to generate professional, polished writing
at a high rate of production. Handwriting must be clear and legible.
Understanding of medical terminology,
anatomy and physiology, diagnostic procedures, pharmacology, and treatment
assessments to the extent required to understand and accurately
transcribe dictated reports. Translate medical abbreviations into their
Skills – Ability to add, subtract, multiply, and divide in all units of
measure, using whole numbers, common fractions, and decimals. Prepare and
interpret charts and graphs. Have the ability to compute ratio and percent.
Ability – Ability to apply common sense understanding to carry out instructions
furnished in written, oral, or diagram form. Ability to apply logic and draw
conclusions based on knowledge. Have the ability to refer to reference
materials to solve problems.
Computer Skills – To perform this job successfully, an individual should be
able to learn and use all functions of electronic medical record software. Must
accurately enter data into a database, search for information, send and receive
email and attachments.
Must be able to type words and
numbers quickly and accurately.
comply with HIPAA confidentiality standards when accessing or communicating
Must be able to work in a fast-paced
work environment and anticipate physician needs to facilitate the flow of
Must be discreet, tactful, and
modest in performance of duties so as not to distract medical staff from
Must show good judgment,
organizational ability, initiative, attention to detail, and the ability to be
PHYSICAL DEMANDS: While
performing the duties of this Job, a Medical Scribe is regularly required to
stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel;
reach with hands and arms and talk or hear. The Medical Scribe is occasionally
required to climb or balance and stoop, kneel, crouch, or crawl. The Medical
Scribe must regularly lift and /or move up to 10 pounds. Specific vision
abilities required by this job include close vision, distance vision, color
vision, depth perception and ability to adjust focus.