Medical Scribe

Community Health Care•Bridgeton, NJ

5d•Onsite

About The Position

The Medical Scribe supports a Primary Care Provider by documenting patient visits accurately and promptly in the electronic health record (EHR). The role reduces the provider’s documentation workload, supports efficient visits, and enables the provider to focus on patient care. The Medical Scribe works under the provider’s direction, and all documentation must be reviewed, corrected as needed, and authenticated by the provider. The scribe prepares charts, participates in daily huddles, documents information communicated by the provider during patient encounters, and supports visit completion and follow-up as directed. The position works collaboratively with the care team and protects patient privacy. The scribe does not independently assess patients, diagnose conditions, recommend treatment, interpret test results, provide clinical advice, choose diagnoses or billing codes, authorize orders or prescriptions, or sign documentation on a provider’s behalf. Work is performed in an outpatient clinical setting and involves frequent computer use, sustained attention, and movement between work areas. Reasonable accommodations may be provided to enable performance of essential job functions. Performance expectations include accurate and complete documentation, timely preparation of notes for provider review, adherence to role boundaries and confidentiality requirements, reliable attendance and punctuality, and effective collaboration with the care team.

Requirements

High school diploma or equivalent.
Knowledge of medical terminology, anatomy, and common primary care conditions, obtained through education, training, or relevant experience.
Strong typing, listening, spelling, and written communication skills.
Ability to document accurately while following a patient-provider conversation.
Proficiency with computers and ability to learn EHR systems.
Strong attention to detail and organization, and ability to manage competing priorities.
Ability to maintain confidentiality and work respectfully with diverse patient populations.

Nice To Haves

Previous medical scribe or healthcare documentation experience.
Experience in primary care, an outpatient practice, or a Federally Qualified Health Center.
Experience with NextGen or another EHR.
Medical scribe training or certification.
Bilingual English/Spanish skills.

Responsibilities

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.
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.
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.
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 promptly report documentation errors or privacy concerns.