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Get to know about the duties, responsibilities, qualifications, and skills requirements of a medical scribe. Feel free to use our medical scribe job description template to produce your own. We also provide you with information about the salary you can earn as a medical scribe.

 

Who is a Medical Scribe?

A medical scribe is a doctor’s assistant who records the patient’s family and medical histories, treatments, allergies, lab results, and any other information that the doctor dictates to them or that is pertinent to the patient’s visit. A medical scribe frequently writes as a doctor would, making sure to check for any inaccuracies because they are familiar with medical terminology and have some clinical expertise. If there are any discrepancies, they alert the doctors, assist in fixing the problem, and even finish the documents. They are not in charge of making decisions regarding the patient’s care or treatment, though.

The scribe electronically captures all information, and their work is available to clinicians who need to review the patient’s medical history. Managers oversee the work of medical scribes and are frequently nurses or quality assurance professionals. Scribes enable doctors to focus on their patients while taking care of their administrative obligations by documenting each event and step of the treatment process. A medical scribe can increase the effectiveness of the doctor-patient connection and guarantee the accuracy of crucial medical records by doing their job well.

 

Kinds of Medical Data Medical Scribes Collect

Medical Records: Each patient will have a distinct medical background and a current medical file. These documents will be entered into the electronic health record by the medical scribe (EHR).

History of Present Illness (HPI): A HPI is a succinct account of the patient’s history that the medical scribe is writing. It covers the context of the patient’s major complaint, previous medical history, symptoms, and other information. Based on the observed physician and patient interaction, the scribe creates an HPI.

Notes of Patient Encounter: The patient will respond to questions from the doctor regarding symptoms, exercise, food, and other topics during the patient visit, which the medical scribe will record. The medical scribe will also need to record any medical examinations performed, such as basic vital signs or imaging exams.

Medical Dictations:  Doctors frequently utilize dictaphones to record notes about the visit and/or their treatment choices. The information is subsequently entered into the electronic health record by scribes after listening to these dictations.

Letters: Sometimes scribes would draft letters of recommendation for physicians or other kinds of writing.

 

Is there any Difference between a Transcriptionist and a Medical Scribe?

Despite their similarities, clinical scribing and medical transcribing only share the result of their labor. The presence of scribes in exam rooms alongside doctors is what sets them apart from other medical professionals. A transcriptionist frequently works from a different room within the same building, from home, or from another building far away.

The primary distinction between transcriptionists and scribes is how they get the medical data they will document. The content of the file is frequently expected to be typed verbatim by the transcriptionist, who receives instructions via dictation. Instead, medical scribes must glean pertinent medical data from patient interactions. This can be challenging because there is often a lot going on during patient visits and wandering off-topic is usual. The task of transcription is made more straightforward because the transcriptionist is spared from the small talk and other dialogue that is customary in a patient-physician relationship.

Many people find it intimidating and downright undesirable to be so close to the action, specially seasoned medical transcriptionists who have established a living by staying out of the spotlight. In addition to being close to the action, scribes are unable to use the pedal that medical transcriptionists use to pause, rewind, and fast-forward a dictation file. Nevertheless, when something is overlooked during a visit, scribes can (and must) ask.

Further than how they obtain the material to document, there are other differences between scribes and medical transcriptionists. One way transcriptionists complete their task so rapidly is by frequently using shortcuts and macros. Unfortunately, not many EHR packages offer this. To save time on repeated information, you can use some favorites and forms. Some typists attempt to overcome these challenges by typing their work on their old platform, then copying and pasting it into an EHR tool. However, this is inefficient and can result in formatting issues.

 

Medical Scribe Job Description

Below are the medical scribe job description examples you can use to develop your resume or write a medical scribe job description for your employee. Employers can also use it to sieve out job seekers when choosing candidates for interviews.

• Assist with office work, including taking calls and getting lab data.
• Make sure that medical test findings are delivered to patients on time.
• Assist in the automated prescription of the medication process.
• Draft recommendation letters for doctors.
• Obtain medical records from other hospitals.
• Record the patient’s medical history.
• Record the results of the medical examination.
• Enter patient data into computers.
• Welcome patients and introduce them to medical staff.

 

Qualifications

1. Education: A high school diploma is typically the minimum needed to work as a medical scribe. However, the majority of businesses choose to hire applicants who have a college degree or a certification like the Certified Medical Scribe Associate (CMSA) or the Certified Medical Scribe Professional (CMSP). Students pursuing a medical degree in college may also hold these professions. Employers continue to recruit them despite their insufficient education since they are well-versed in medical language.
2. Experience: Medical Scribes typically need at least a year’s worth of experience working with electronic health records. Employers typically favor applicants with recent medical scribing experience, urgent care experience, and a working knowledge of the majority of medical terminologies. An online or in-person training program is often completed by Medical Scribes to acquire this knowledge.
3. Completion of a good entry-level Medical Scribe Curriculum: Comparatively speaking to other entry-level occupations in other industries, medical scribes need a rather high level of education and comprehension for their work. It will be a beneficial skill to have before becoming a medical scribe to have completed a thorough scribe training course and have certification of its completion.
4. Regular and continued education and skills improvement: Government regulations, payment coding obligations, and the newest treatments and techniques are all continually changing in the healthcare sector. The ongoing and consistent skill development is one of the main advantages of being a medical scribe. Additionally, you should be able to type quickly and accurately (70 wpm or higher). The most crucial “talent” for anyone going into the medical sector may just be compassion, understanding, the desire to help those in need, and an innate desire for growth.

 

Essential Skills

1. The Readiness to Learn: There is a lot to learn for the majority of candidates for a position as a medical scribe. You’ll probably need to gain important skills and information within your first week of work, including comprehending government legislation, clinical role and function, and familiarity with using EHR documentation. Additionally, a willingness to learn is an essential quality to have because you’ll be doing a lot of in-person training and shadowing other medical scribes and doctors at the start of your job experience.
2. Perseverance: The clinical environment can be quite stressful and hectic. You might constantly be surrounded by controlled chaos and life-or-death choices, particularly if you were applying to work as a medical scribe in urgent care or an emergency hospital. A medical scribe may nevertheless experience pressure in smaller clinics and specialties because patients frequently visit clinics because they are ill or have other co-morbid conditions. For this position, it’s important to be able to maintain composure and perseverance under pressure.
3. Self-motivation: Being a self-starter is a key quality because the fast-paced nature of a medical scribe’s employment frequently necessitates working alone. Medical scribes’ main duty is to relieve doctors of a load of EHR documentation, hence they must be motivated on their own with little direction from doctors or other healthcare professionals.
4. Positive Mindedness: An optimistic outlook is generally just a nice quality to have for any career. A positive outlook is a must if you’re considering a profession as a medical scribe. You interact with patients in close quarters with doctors for a significant chunk of the day. As a result, maintaining a positive outlook can help you build relationships with the doctors you work with and defuse uncomfortable circumstances. Furthermore, correct electronic documentation is essential to billing and revenue for a healthcare institution, and the medical scribe position is one of the major contacts of the patient interaction. But because medical scribing is an entry-level job with entry-level pay, it is important to have a positive outlook.
5. Wearing a Good Smiling Face: A medical scribe meets with doctors and takes part in most patient interactions, thus it should go without saying that smiling is a fundamental skill. To boost patient satisfaction for the healthcare company you work for, greet each patient with a dazzling smile.
6. Knowledge of Medical Jargons: The ability to comprehend medical language, anatomy, procedure and diagnosis names, and other related concepts is crucial for a medical scribe. Because pre-medical and pre-physician assistant students frequently have a high degree of understanding and mastery of this terminology, most businesses searching for medical scribes look for them. Additionally, because pre-health students make up the majority of applicants, most medical scribes are very skilled in this field. It doesn’t imply that you can’t be a competent medical scribe if you don’t already have a high level of knowledge in this field. This relates to the first talent to possess, which is the desire to learn. If you have the time, brush up on your knowledge in this area by enrolling in a scribe training course.
7. Great Typing Speed: For all medical scribes, speed typing is essential. It’s crucial that they can record all the crucial information before it’s too late, whether they are actual medical scribes or virtual one. Medical scribes observe appointments and patient interactions as they take place. The scribe must be able to enter information accurately and quickly for records because there isn’t time to ask doctors to repeat themselves. In other words, you won’t be a good scribe if you type slowly and ask the doctor too many questions. An average of 40 words per minute are typed (wpm). If you want to be an excellent medical scribe, you must be much faster than this.
8. Verbal and Digital Communication Skills: It should go without saying that a medical scribe needs to be able to communicate effectively. Even if your assistance to the doctor is not medical, it still counts as assistance. You must have the ability to react swiftly and formulate queries effectively. During appointments, verbal communication is crucial, and digital communication is crucial for any prospective follow-up. You will exchange confidential information and communicate with both office employees and medical professionals. Make sure your abilities are on par.
9. Professionalism and Organizational Skills: When you work as a medical scribe, you must maintain organization. There is no room for mistakes or wandering off course. Remember that this is a professional writing position and that you will be handling information that you cannot lose track of; as a result, you run the danger of your company failing to comply with HIPAA. When it comes to employing medical scribes, other desk occupations, writing tasks, and secretarial duties will be beneficial.
10. Administrative or Technical Writing Expertise: The primary responsibility of a medical scribe is writing. This means that to succeed, you must possess strong administrative and technical writing abilities. While there is still a place for those who have previously focused on academic or creative writing if you want to be a successful medical scribe you should focus on professional writing.
11. Listening and Comprehension Skills: Medical scribes communicate with doctors during a real-time patient visit via a video or audio call, though depending on the employer, they also frequently meet in person. Scribes have access to private data and patient medical records. As a result, they must accurately and swiftly take down any notes from the talk.
12. Keen Attention to Details: As they are in charge of understanding the physician’s dialogue and recording the specifics into the EHRs, medical scribes must have an eye for detail. Additionally, scribes need to be able to spot mistakes when creating other clerical papers. They must be able to correct any errors in the documentation or raise the issue with the doctors or supervisors.
13. IT Proficiency: Medical scribes need to comprehend and accurately record information since they may communicate with doctors via live video or audio calls. Advanced typing and data entry abilities are frequently beneficial for this. A smooth encounter can be ensured by having the ability to quickly go through a database to consult a patient’s medical history or any other information the doctor may need.
14. Ability to Manage Time Efficiently: Medical scribes must be able to manage their time well to be present for patient meetings with doctors, whether they take place in person or via video or audio call. They frequently check the doctor’s schedule to make sure it coincides with their own. To ensure that a medical office runs well, time management can also keep scribes organized and on schedule for the day.

 

How to Become a Medical Scribe

1. Successfully Complete your High School: To work as a medical scribe, you must have graduated from high school. Biology and English are good choices since they can help you get familiar with human anatomy and build the skills necessary for effective communication.
2. Obtain your Certification: Numerous organizations offer training programs to assist people to become medical scribes. These are typically four to six-month courses that emphasize typing and the teaching of medical terminology. They might also talk about ways to communicate better in written and spoken form when in a healthcare setting. Many of these institutions offer paid internships and other opportunities for students to gain real-world experience. Once finished, they assist students in landing jobs with businesses that provide scribing services to numerous hospitals.
3. Acquire Relevant Experience: You may be able to find employment as a medical scribe if you have prior experience as an administrative assistant, transcriber, or even customer service representative. So that a hiring manager is more aware of the transferable talents you have acquired that you can employ in a new career, include these kinds of experiences on your CV. Even while a hospital or other medical facility might provide you with on-the-job training, having some experience could help you stand out from the competition.
4. Submit an Application: You can express interest in a position by applying. As a result, you must apply to the relevant medical facility and inform them of your intention to work as a medical scribe. Many of these applications are available online. Therefore, you must apply online to the institute of your choice. Please proceed to use that method if they request that you submit your application differently.
5. Attend Interview: If your application is accepted, you will receive an invitation to an interview. Although this interview is typically conducted online and through a media platform, certain health centers might want to witness your skills in action. You must act appropriately during your interview with all decency, poise, and style. Each question must be answered with assurance, always demonstrating a willingness to improve.
6. Write a Typing Test: As a medical scribe, accurate data documentation accounts for a sizable portion of your work. That arranging calls for a lot of quickness. Consequently, you must be able to type quickly to work as a medical scribe. You will go to a typing test after your interview is finished. The purpose of the typing test is to evaluate your comprehension, speed, and aptitude for gathering, storing, and organizing data. Therefore, it’s quite simple for anyone to choose the information they need thanks to your organization. The typing test is often administered by the health facility of your choice, and the methodology varies by industry.
7. Receive the Offer: As soon as your interview and typing test is finished, you must wait while your preferred health institute compiles the results. Depending on how many other applications there are, you might need to wait up to two weeks. To accept the offer to work as a medical scribe, make sure to continue monitoring your mail. The specifics of your timetable, job hours, and other information are entirely up to your institute.
8. Attend Training: You must go to training as soon as you accept the offer. To promote uniformity, this training places a special emphasis on the industry’s method of conducting business.

 

Where to Work as a Medical Scribe

• Hospitals
• Medical Clinics
• Office of the Doctor

 

Medical Scribe Salary Scale

A medical scribe’s annual income in the US averages $35,000 and frequently runs from $29000 to $38000. The hourly wage is typically between $14 and $15.

In the UK, the average yearly wage for a medical scribe is £19,953, but this figure can change depending on several variables, including the number of years of experience, degree of education, employer’s location, and health care facility you work for. Additionally, you may be eligible for additional annual cash bonuses and employee benefits including health, life, and vacation time.

 

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