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