Medical Scribe

Description

Position Summary

The Medical Scribe supports a Primary Care Provider by documenting patient visits accurately and promptly in the electronic health record (EHR). This position helps reduce the provider’s documentation workload, supports efficient patient visits, and allows the provider to focus on patient care.

The Medical Scribe works under the provider’s direction. All documentation must be reviewed, corrected as needed, and authenticated by the provider.

Essential Duties and Responsibilities

Visit Preparation

• Review the scheduled patient list and prepare charts according to established workflows. • Identify missing records and notify the appropriate team member. • Participate in daily huddles to coordinate visit needs with the provider and care team.

Documentation During Patient Visits

• Accompany the provider during patient encounters, with the patient’s permission and according to organizational procedures. • Document the history of present illness, review of systems, examination findings, assessment, and treatment plan as communicated by the provider. • Record patient education, follow-up instructions, referrals, and other information discussed during the visit. • Enter information clearly and accurately using approved medical terminology, templates, and abbreviations. • Ask the provider to clarify incomplete or unclear information without making clinical assumptions.

Visit Completion and Follow-Up

• Prepare or pend orders and referrals only as directed by the provider and permitted by organizational policy and EHR access permissions. • Route documentation and administrative follow-up needs to the appropriate staff. • Track outstanding documentation and bring unresolved items to the provider’s attention. • Make provider-directed corrections while preserving the integrity of the medical record.

Teamwork and Confidentiality

• Work collaboratively with providers, nurses, medical assistants, registration staff, and other care team members. • Protect patient privacy and handle confidential information according to organizational requirements. • Maintain professional, respectful communication with patients and staff. • Complete required training and report documentation errors or privacy concerns promptly.

Scope of the Role