Medical Scribe-Clinic

Job Description

Job Description

Medical Scribe-

The Medical Scribe provides real-time documentation support to physicians and other healthcare providers by accurately recording patient encounters, medical histories, and treatment plans into the electronic health record (EHR). This position allows providers to focus more on direct patient care while ensuring accurate and timely medical documentation.

Essential Duties and Responsibilities :

Accurately and efficiently document patient histories, physical exams, assessments, and treatment plans as stated by the provider during patient encounters.

Enter diagnostic test results, procedures, and orders into the EHR as directed by the provider.

Maintain accurate, thorough, and up-to-date medical records for all assigned patients.

Review and prepare patient charts prior to appointments to ensure all relevant information is available.

Assist providers in navigating the EHR system, locating information, and retrieving results or documentation.

Ensure compliance with confidentiality, privacy, and security standards (HIPAA).

Communicate effectively with providers, nursing staff, and other members of the healthcare team.

Identify and flag discrepancies or missing information in documentation for provider review.

Support the clinical team by helping maintain workflow efficiency during patient visits.

Qualifications :

Education : High school diploma or equivalent required; college coursework in health sciences or pre-med strongly preferred.

Experience : Previous experience as a scribe, medical assistant, or in a healthcare setting preferred but not required.

Licensure / Certification : None required; medical terminology training or certification preferred.

clinic