Medical Scribe

POSITION PURPOSE

The role of the Medical Scribe is to assist medical providers in documentation of patient encounters. Scribes accompany the provider into the exam room and document the patient-provider encounter as it is verbalized in real time. Scribes require access to Electronic Medical Records to gather data for the provider, including but not limited to prior medical records and lab/radiology results. The goal of a scribe is to allow the provider to focus directly on the patient while maintaining accurate documentation. Scribes are unlicensed and do not participate in patient care. They require no training or background in the medical field. A scribe may not act independently and all documentation is reviewed and validated by the provider before submission.

ESSENTIAL FUNCTIONS OF POSITION

• Accompany provider into the examination area and transcribe medical findings in real time
• Complete additional needed physician documentation
• Inform the provider when lab results are completed and enter results into chart
• Look up pertinent medical records from prior medical visits
• Track and enter the results of radiology reports
• Document all medical procedures performed and ordered by the provider
• Enter the patients plan of care into the Electronic Medical Record database
• Follow all documentation compliance standards
• Various additional tasks delegated by the Lead Scribe and Corporate