The primary role of the medical scribe is to assist the physician with documentation of each patient’s medical chart.
The scribe accompanies the physician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician. The scribe documents accurately the physician’s encounter with the patient and others present.
The scribe, under the direction of the physician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc.
The scribe documents any procedures performed by the physician on the medical chart. These procedures might include summaries of suture placements or Advanced Cardiac Life Support measures taken by the ED physician or other procedures as might be done in a medical office.
The scribe transcribes any consultations or discussions with family and/or the patient’s private physician or the on-call physician.
The scribe completes the patient’s chart by entering into the record results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data in order to get the patient’s workup complete so that the physician is able to close the encounter.
The scribe lists all proper diagnoses as well as any discharge/follow up instructions and prescriptions, as dictated by the physician.
The scribe does not directly assist with patient care. This includes NOT having any direct physical contact with patients, NOT administering medications, NOT relaying verbal orders, and NOT adding anything to a medical record that is not under the direct order/supervision of their physician.
The physician approves every task of the scribe and takes full responsibility, with their signature, for the information recorded in their patients’ charts.
High school diploma required.
College sophomore status or higher preferred.
Pre-health career track preferred but not required.
Familiarity with a healthcare setting and ability to demonstrate knowledge of medical terminology strongly preferred.
Excellent English verbal and written communication skills.
Strong customer service and computer application skills required. Ability to type quickly and accurately.
Displayed passion for healthcare is a must!
Additional assets are: ability to multi-task, ability to maintain a positive and professional demeanor under stressful circumstances, self-directing and pro-active after understanding goals, strong analytical skills, time-management skills, flexibility to work unusual hours (ED only) including nights and weekends, professional appearance.