Medical Scribe

Position: Volunteer Medical Scribe

Reports to: Volunteer Coordinator, Clinic Manager and Medical Director

Job Description: A medical scribe is responsible for capturing, in real-time, accurate and detailed documentation of patient encounters on the EHR system (Amazing Charts) for healthcare providers during clinic hours. A scribe allows the provider to give high quality care and attention to the patient diagnosis and treatment plan as well as optimize the provider’s efficiency and productivity. Training is provided.

Core Responsibilities:

1. Accompany the physician during the office visit with the patient. You will be present for the duration of the visit with the exception of parts of the physical examination.
2. Record the History of Present Illness (HPI), Review of Systems (ROS), Physical Exam, and Assessment and Plan.
3. Enter/maintain the patient’s Past Medical History, Social History, Family History, Current Medications, and Problem List.
4. Enter the visit diagnoses, lab orders, and prescriptions.
5. Locate patient information such as lab tests, prior medical records, demographic information, etc. all via the EHR system.
6. Ensure proper communication between nurses and providers regarding patients.
7. Assist the provider in navigating the EHR.