Scribe
About The Position
This role involves real-time documentation of patient encounters within the Electronic Health Record (EHR) during exams. The scribe will be responsible for medical charting, including patient history, physical exams, diagnoses, treatment plans, and physician notes. Additionally, the scribe will provide support for order entry, entering lab, imaging, and prescription orders as directed by the provider. Chart preparation, including reviewing labs, prior visits, and history, is also a key responsibility. The scribe will assist providers in maintaining efficient patient flow and ensure that all records meet legal, regulatory, and billing requirements. Support for accurate medical coding (ICD-10, CPT) may be required, and the scribe will coordinate with providers and clinical staff to clarify documentation. Maintaining strict adherence to HIPAA and patient privacy standards is essential.
Requirements
- Medical Terminology Knowledge
- Strong Typing & Data Entry Skills (fast and accurate)
- Attention to Detail
- Active Listening & Note-Taking
- Time Management & Multitasking
- Computer/EHR Proficiency
- Professional Communication Skills
- Confidentiality & Ethical Judgment
Nice To Haves
- Experience in a clinical or healthcare setting
- Familiarity with EHR systems (e.g., Epic Systems, Cerner)
- Understanding of medical billing and coding basics
- Pre-med, nursing, or healthcare-related education background
Responsibilities
- Accurately document patient encounters in the Electronic Health Record (EHR) during exams
- Record patient history, physical exams, diagnoses, treatment plans, and physician notes
- Enter lab, imaging, and prescription orders as directed by the provider
- Review and prepare patient charts prior to appointments (labs, prior visits, history)
- Assist providers in maintaining efficient patient flow
- Ensure records meet legal, regulatory, and billing requirements
- Support accurate medical coding (ICD-10, CPT) when applicable
- Coordinate with providers and clinical staff to clarify documentation
- Maintain strict adherence to HIPAA and patient privacy standards
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
