Position Summary: The duties of a Scribe are to document the physician dictated patient history, physical examination, family, social, and past medical history as well as document procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient’s encounter in the Emergency Department or other clinical medical setting. Scribes are not patient care providers, nor are they part of the hospital staff; they are solely employed by EMSOC/ScribeMD and as such are the physician’s representative and employee.

Basic Qualifications:

• Education: High School graduate. Preferred: Healthcare student – medical school, nursing, advanced practice provider, medical assistant, LPN, RN. Some college level education including health related professions/study.

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Experience: Prior medical scribe experience or at least two years medical office experience (MA, medical receptionist, etc.

• Licensure, Registrations & Certifications:

This job does not require a license, registrations or certifications

Essential Job Responsibilities:

• Scribes accompany the physician upon patient interview and examination.

• Scribes document the physician dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies.

• Scribes document physical examination findings and procedures as performed by the physician.

• Scribes document the results of laboratory and radiographic studies as dictated by the physician.

• Scribes document the correct time of patient care related activities, including physician to physician communication, family communication and re-examination of the patient.

• When the physician concludes the patient’s encounter, the physician will review all documentation completed by the Scribe, make any necessary amendments, and sign the chart. The physician is ultimately responsible for documentation of the patient’s encounter within the medical record (EHR).

• The physician and the Scribe will stay current on medical record needs via review inbox/message centers, coding queries and delinquent information requests, review patient status, delays, and any other care-related issues.

• All orders for patient care must be communicated by the physician and not the Scribe.

• Scribes do not participate in any patient care and should refer all requests related to patient care to the responsible physician or nursing staff; including, but not limited to, transporting specimens, answering phones, assisting patients, calling physicians, etc. Perform other related job duties as assigned.