Medical Scribe Job Description Template
The Medical Scribe is responsible for documenting the physician’s dictated patient encounter in the medical record. The scribe also enters orders into the electronic health record (EHR) at the direction of the physician and assists with collecting patient data required for documentation. The scribe works alongside the physician to help create a more efficient workflow and improve patient care. Education: High school diploma or equivalent is required. Some college coursework preferred but not required. Skills: Excellent written and verbal communication skills are essential, as well as strong attention to detail. Must be able to type quickly and accurately. Familiarity with medical terminology preferred but not required. Compensation: $12-$18 per hour
Medical Scribe Job Responsibilities
- Listen to and document patient encounters with physicians in real time
- Use medical terminology to accurately transcribe physicianpatient interactions
- Create detailed and accurate patient records
- Follow strict confidentiality protocols when handling protected health information (PHI)
- Adhere to quality standards set by the medical scribe program or organization
- Complete training on electronic medical record (EMR) systems and other required software
Objectives
- To provide an accurate and complete record of patient encounters in the medical setting
- To work closely with physicians and other health care providers to document patient history, physical examination findings, diagnostic tests, treatment plans, and other important clinical information
- To maintain confidentiality of all patient information
- To keep up to date on medical terminology, documentation guidelines, and regulatory requirements
- To ensure timely and accurate transcription of physician orders
- To facilitate communication between the physician and other members of the health care team by providing clear and concise documentation
Medical Scribe Job Skills & Qualifications Needed
- There are no specific skills or qualifications needed to be a medical scribe. However, scribes must have excellent written and verbal communication skills, as well as strong attention to detail. They should also be able to type quickly and accurately.