Job Summary:
Job duties and responsibilities of a medical scribe include and are limited to the following:

1. Thorough and accurate documentation of all encounter visits and procedures as they are being performed by the physician, including but not limited to:


+ Patient medical history / and physical exam

+ Procedures and treatments performed by healthcare professionals, including nurses and physician assistants

+ Accurate and thoroughly scribed Physician-dictated diagnoses, medications and instructions for patient or family members

+ Under direction of the provider, prepare accurate referral letters as requested by the provider.


2. Medical scribe may spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical scribes ensure that all clinical data, lab or other test results, the interpretation of the results ...