Medical Scribe

Medical Scribe

The Medical Scribe supports a Primary Care Provider by documenting patient visits accurately and promptly in the electronic health record (EHR). This position helps reduce the provider's documentation workload, supports efficient patient visits, and allows the provider to focus on patient care.

The Medical Scribe works under the provider's direction. All documentation must be reviewed, corrected as needed, and authenticated by the provider.

Essential Duties and Responsibilities

• Visit Preparation
• Review the scheduled patient list and prepare charts according to established workflows.
• Identify missing records and notify the appropriate team member.
• Participate in daily huddles to coordinate visit needs with the provider and care team.

Documentation During Patient Visits

• Accompany the provider during patient encounters, with the patient's permission and according to organizational procedures.
• Document the history of present illness, review of systems, examination findings, assessment, and treatment plan as communicated by the provider.
• Record patient education, follow-up instructions, referrals, and other information discussed during the visit.
• Enter information clearly and accurately using approved medical terminology, templates, and abbreviations.
• Ask the provider to clarify incomplete or unclear information without making clinical assumptions.

Visit Completion and Follow-Up

• Prepare or pend orders and referrals only as directed by the provider and permitted by organizational policy and EHR access permissions.
• Route documentation and administrative follow-up needs to the appropriate staff.
• Track outstanding documentation and bring unresolved items to the provider's attention.
• Make provider-directed corrections while preserving the integrity of the medical record.

Teamwork and Confidentiality

• Work collaboratively with providers, nurses, medical assistants, registration staff, and other care team members.
• Protect patient privacy and handle confidential information according to organizational requirements.
• Maintain professional, respectful communication with patients and staff.
• Complete required training and report documentation errors or privacy concerns promptly.

Scope of the Role

The Medical Scribe does not independently assess patients, diagnose conditions, recommend treatment, interpret test results, provide clinical advice, or select diagnoses or billing codes. The scribe does not independently authorize orders, prescriptions, or referrals, or sign documentation on behalf of a provider. Additional duties requiring separate credentials must be specifically authorized.

Requirements

Required Qualifications

• High school diploma or equivalent.
• Knowledge of medical terminology, anatomy, and common primary care conditions, obtained through education, training, or relevant experience.
• Strong typing, listening, spelling, and written communication skills.
• Ability to document accurately while following a patient-provider conversation.
• Proficiency with computers and ability to learn EHR systems.
• Strong attention to detail, organization, and ability to manage competing priorities.
• Ability to maintain confidentiality and work respectfully with diverse patient populations.

Preferred Qualifications

• Previous medical scribe or healthcare documentation experience.
• Experience in primary care, an outpatient practice, or a Federally Qualified Health Center.
• Experience with NextGen or another EHR.
• Medical scribe training or certification.
• Bilingual English/Spanish skills.

Working Conditions and Physical Requirements

Work is performed in an outpatient clinical setting and requires frequent computer use, sustained attention, and the ability to move between work areas. Reasonable accommodations may be provided to enable performance of essential job functions.

Performance Expectations

• Accurate, complete documentation that reflects the provider's findings and decisions.
• Timely preparation of notes for provider review.
• Consistent adherence to role boundaries and confidentiality requirements.
• Reliable attendance, punctuality, and effective collaboration with the care team.

CompleteCare Health Network