The central role of the Medical Scribe is to relieve the physician of clerical or secretarial duties; thus allowing the physician to focus more directly on clinical care. The scribe is an unlicensed person and exclusively non-clinical.

You will not touch patients and will not engage in any type of patient care.

Your role is limited to documentation and efficiency management for the physician.

As a scribe, you observe the physician during patient encounters and perform documentation on the physician’s behalf. Under the direction of the physician, you enter information into the patient’s electronic or written chart. All documentation is reviewed and edited by the physician. It is signed with an attestation by the provider that the scribed chart accurately reflects all work, treatment, procedures, and medical decision making performed by them.

Your Duties and Responsibilities are:

• Chart in real-time as the provider assesses and examines the patient

• Document the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultations

• Record provider-dictated diagnoses, prescriptions and instructions for patient follow-up

• Locate and obtain past medical histories, previous charts, past results and studies

• Transcribe ancillary test results and their interpretations

• Check on the progress of labs, imaging studies, and other patient data

• Retrieve and display current and past EKGs and imaging films (e.g. X-rays) for the provider to review and record provider’s interpretation

• Understand basic ICD-10 documentation requirements

• Comply with all national and local PHI laws including in HIPAA and HITECH

• Comply with all facility, department, company policies and procedures

• Perform a variety of other non-clinical tasks specific to the local facility

You posses the following:

• High school diploma or the equivalent

• Exemplary work ethic and professionalism

• Excellent verbal and written communications skills

• Ability to adapt to individual site needs

• Strong computer skills – technological savvy

• A typing speed of 50+ WPM

Training

Upon hiring, you are expected to successfully complete the following requirements:

Classroom training:

• Clinical training
• Complete a final exam
• Initial competency assessment
• Facility-specific training

The physical demands described 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 functions.

• Must be able to stand for long periods of time

• Frequently required to stand, walk, sit, use hands, handle documents, bend and stoop as needed, and reach with hands and arms

• Required to use a keyboard and computer regularly

Doctors Save Lives.

Scribes Save Doctors.

When ScribeAmerica was founded in 2003, the company transformed what was previously a cottage operation into a national industry. ScribeAmerica pioneered new processes and technologies, quickly becoming the nation’s most frequently used medical scribe company. Today, ScribeAmerica has nearly 10,000 employees in 48 states. Our scribes are assisting physicians in nearly 1,300 sites. We regularly hear testimonies from clients who say scribes have transformed their practice.

“Scribes allow doctors to get back to what they should be doing: doctoring.”