Scribe

Primary Responsibilities Real-time Documentation:

Accurately document patient encounters in the Electronic Health Record (EHR) during exams

Medical Charting:

Record patient history, physical exams, diagnoses, treatment plans, and physician notes

Order Entry Support:

Enter lab, imaging, and prescription orders as directed by the provider

Chart Preparation:

Review and prepare patient charts prior to appointments (labs, prior visits, history)

Clinical Workflow Support:

Assist providers in maintaining efficient patient flow

Documentation Compliance:

Ensure records meet legal, regulatory, and billing requirements

Coding Assistance:

Support accurate medical coding (ICD-10, CPT) when applicable

Communication:

Coordinate with providers and clinical staff to clarify documentation

Confidentiality:

Maintain strict adherence to HIPAA and patient privacy standards Required Skills 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 Preferred Skills / Qualifications 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