Medical scribes perform a wide variety of transcription related tasks such as inputting patient data (such as history or symptoms), recording examination results, and preparing charts Depending on the facility and company, this may involve electronic forms of documentation or physical paperwork, but organizing and cataloging are generally a large part of the job. The daily operations of the position involve close work with physicians and other employees in the medical environment. Medical scribes are generally directly supervised by a nurse manager or similar professional.
Medical scribes generally work in indoor environment such as a hospital or office. These individuals should have basic computer skills, excellent communication skills and be able to use common office devices such as computers, faxes, document scanners, and filing systems. These professionals generally work during regular office hours, although overtime and alternative hours may be required depending on the employer and position.
A high school diploma or equivalent is generally required for this position. Medical scribe positions generally do not often require any form of specialized experience with medical practice. Because of their job’s access to sensitive information, however, background checks and clean criminal records are usually required. Certifications for medical transcription work or as a Certified Healthcare Documentation Specialist (CHDS) certification are sometimes required, but for many positions they are simply preferred.
Medical Scribe Tasks
Comply with all legal and ethical requirements for medical documentation.
Alert physician when medical record is incomplete or medical documentation contains mistakes or inconsistencies .
Collect, organize, and catalog data for physician quality reporting system and other quality initiatives to increase patient compliance and improve outcomes.
Document medical visits and procedures as they are being performed by the physician accurately and thoroughly.
Perform clerical tasks as needed by the physician including faxing, phone calls, referral letters.