Description:
JOB OVERVIEW:
The Medical Scribe role is responsible for providing documentation support to healthcare providers by accurately recording patient encounters in the Electronic Health Record (EHR). This position assists providers by capturing clinical information during patient visits, maintaining accurate medical records, and supporting efficient patient care delivery in a clinical environment.
ESSENTIAL FUNCTIONS INCLUDE, BUT ARE NOT LIMITED TO:
- Accompany providers during patient exams and accurately document patient encounters, including history, physical exam findings, assessment, and plan
- Update and maintain patient information in the Electronic Health Record (EHR), including medical history, test results, diagnoses, and prescriptions
- Assist with chart preparation, medical documentation, and record organization
- Prepare referral letters and other clinical documentation as needed
- Maintain accurate and timely documentation while supporting provider workflow
- Organize medical records and ensure documentation is maintained appropriately
- Follow HIPAA guidelines and maintain confidentiality of all patient information
- Maintain operations by following policies and procedures (HIPAA, OSHA)
- Perform other duties as assigned
Requirements:
QUALIFICATIONS/LICENSE:
None required
EDUCATION:
- High School Diploma or equivalent required
- College-level science coursework or Athletic Training Certification (ATC) preferred
EXPERIENCE:
- Medical office experience preferred
- Experience with medical terminology, anatomy, pharmacology, and Electronic Health Record (EHR) systems.
- Understanding of workersโ compensation processes preferred
SKILLS:
- Strong understanding of medical terminology and clinical documentation
- Ability to accurately document patient encounters with attention to detail
- Strong written and verbal communication skills
- Excellent listening and multitasking abilities in a fast-paced clinical environment
- Proficient computer skills with the ability to navigate EHR systems and databases
- Ability to type accurately and efficiently (60+ WPM)
PHYSICAL REQUIREMENTS:
The physical demands describe here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
- Specific vision requirements include the ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus.
- While performing the duties of this job, the employee is regularly required to talk and hear.
- Possess the ability to fulfill any office activities normally expected in an office setting, to include, but not limited to: remaining seated for periods of time to perform computer based work, participating in filing activity, lifting and carrying office supplies (paper reams, mail, etc.)
- Frequently required to stand, walk, sit, use hands to feel, and reach with hand and arms.
- Occasionally lift and/or move over 25 pounds.
- Fine hand manipulation (keyboarding).
- Travel may be required to existing or new Motion locations.