Medical Scribe Job Description for Resume

Updated on: October 1, 2018

Medical Scribe Qualifications

To be considered eligible to work as a medical scribe, you need a high school diploma or a GED equivalent, even though some hiring managers might want you to possess a degree as well. Apart from education, it is important for medical scribes to possess some knowledge of medical procedures as they relate to hospitals and clinical settings, and have it in them to perform a wide variety of tasks at the same time. Exceptional organization skills and the ability to create and maintain medical records with accuracy and completeness are all prerequisites of working as a medical scribe.

In addition to this, one has to possess exceptional communication skills, as one needs to be able to clearly and effectively communicate with people from different backgrounds. A lot of the work of a medical scribe revolves around creating and maintaining records, which is why it is important that he or she understands the use of hospital databases, specifically the EHR (Electronic Health Records) system.

If working as a medical scribe is on the charts for you, the following list of job duties will make it easy for you to apply for the job:

Medical Scribe Job Description for Resume

• Accompany physicians to patients’ rooms, and acquire basic information for intake purposes.
• Accurately document medical visits performed by accompanying physician, by following set patterns of documentation.
• Observe medical examinations and procedures, and ensure that appropriate notes are taken and recorded.
• Provide patients with education regarding the risks and benefits of different procedures and treatments.
• Note down the physician-dictated diagnosis, prescriptions, and instructions, aimed at self-care and follow-up.
• Prepare referral letters for further treatment or services, upon the instructions of the physician.
• Transcribe patients’ orders such as laboratory tests and radiology studies, along with medical information.
• Complete patients’ charts by transcribing results of consultations, and other pertinent data related to patients.
• Record diagnosis, discharge, prescription, and follow-up information into the electronic health records systems.
• Document history of patient illness, family and social background, review of systems, and physical examinations.
• Ensure that all ordered tests are performed in a safe and accurate fashion, and that results are expedited and recorded properly.