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1

medical scribe

  • Accompany provider into exam room to document all provider-patient interactions.
  • Thoroughly record patients’ medical history, vitals, and visits in medical records.
  • Manage and sort documents in EMR. 
  • Fax medical documents to and coordinate with other providers and/or practices.
  • Identify, compile, abstract, and code patient data, using standard classification systems.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
2

medical scribe

  • Editing and making patient charts acceptable for doctor use and insurance billing. 
  • Knowledge and navigation of relevant EMR systems 
  • Knowledge of medical terminology. 
  • Responsible for multitasking active listening and typing with speed. 
  • Exceptional personal and professional skills to work alongside doctors in a variety of settings.
3

medical scribe

  • Accompanied attending physician during rounds for both inpatient and outpatient settings in the Shock Trauma ICU, Trauma Floor, and Pediatric GI clinic and assisted in recording patient history and physical exam findings into the electronic medical record
  • Organized and transcribed results for patients’ laboratory tests, medications and imaging studies
  • Documented procedures completed and recorded diagnostic test results
  • Documented all diagnoses, treatment plans, prescriptions, and discharge and follow-up information
4

medical scribe

  • Assist cardiologists in medical documentation and other clerical duties using EMR applications to help increase their efficiency and productivity.
  • Worked along side the ER medical providers to record the interaction between the provider and the patient as the patients medical chart. Would record things like the patients medical history and reason for the immediate visit to the ER along with results of the physical exam and any lab results. Would finish the patients chart with the provider diagnosis and with their patient plan.
  • Helped increase provider, patient interactions.
  • Made seeing patients occur more quickly and efficiently.
5

medical scribe

  • Documented complete information about examinations, treatment plans, lab results and other details directly into charts.
  • Scanned and filed medical records in alphabetical order to maintain organized and up-to-date filing system. 
  • Selected appropriate ICD-10 and CPT codes for records.
  • Stayed on top of current patient loads to facilitate efficient and organized workflow.
  • Accompanied physicians through day in fast-paced, stressful environments.