Medical Scribe

1. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician they are working for, including but not limited to:

• Patient medical history and physical exam
• Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
• Patient education and explanations of risks and benefits.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.

2. Dictation/faxing/phone calls and clerical tasks.

• Prepare referral letters as directed by the physician, via dictation or summary of the medical record.
• Ensures that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.
• Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls and other clerical tasks as assigned.

3. Report inconsistencies in medical documentation and correct the information in order to reduce errors.

• All addenda must be signed off by a physician.
• Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.
• Alert physician when the chart is incomplete.
• Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

4. Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.

• Assist in developing and maintaining systems to track patient follow up and compliance.

5. Other duties as assigned.