Top Medical Scribe Skills

Below we've compiled a list of the most important skills for a Medical Scribe. We ranked the top skills based on the percentage of Medical Scribe resumes they appeared on. For example, 24.7% of Medical Scribe resumes contained Patient Care as a skill. Let's find out what skills a Medical Scribe actually needs in order to be successful in the workplace.

The six most common skills found on Medical Scribe resumes in 2020. Read below to see the full list.

1. Patient Care

high Demand
Here's how Patient Care is used in Medical Scribe jobs:
  • Facilitated patient care by documenting physician-patient interactions
  • Perform all documentation for provider-Organize patient information from ED visit-Notify provider on updated test results-Collaborate with provider to provide efficient patient care
  • Demonstrated organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care.
  • Participate in delivering patient care in addition to maintaining comprehensive records of each appointment.
  • Communicate with assigned medical assistant regarding patient care.
  • Maximize physician availability for direct patient care.
  • Follow up on lab reports and consult requests from different medical departments to ensure efficiency in patient care delivery 5.
  • Participated in every stage of patient care from the review of triage information to the patient's discharge or admission.
  • Assist in providing excellent patient care through effective and efficient communication between myself, the physician and fellow staff members.
  • Partnered with the physician to deliver the pinnacle of efficient patient care in a stressful and unique environment.
  • Excel in fast-paced, stressful clinical department settings; assist physicians with patient care plans, increasing productivity.
  • Work directly with physicians to ensure efficient patient care by tracking relevant information for medical record.
  • Documented the entire patient encounter to allow to physician to provide optimal and efficient patient care.
  • Facilitate supplemental patient care through communication with outside pharmacies and with patients' insurance companies.
  • Worked with nurses throughout the Emergency Department with any other patient care that is needed.
  • Demonstrate the knowledge and skills necessary to document patient care as dictated by a provider.
  • Work alongside physicians to gain diverse experience in patient care practices and treatment techniques.
  • Monitored lab, imaging, and previous medical history results to expedite patient care.
  • Instructed on notation, patient care, proper charting, and time management.
  • Documented medical charts for physicians in real-time as physicians are providing patient care.

Show More

2. Medical Records

high Demand
Here's how Medical Records is used in Medical Scribe jobs:
  • Maintained patient electronic medical records to help physicians optimize patient interaction to assure quality care while matriculating hundreds of clinical hours.
  • Assisted Emergency Department physicians in accurately documenting and transcribing patient encounters Audited patient medical records to ensure their accuracy and completion
  • Maintained confidentiality of electronic medical records, and patient confidentiality in compliance with the Privacy Act and HIPAA regulations.
  • Obtained medical records from other facilities and performed literature searches on medication safety and high-risk interventions.
  • Increased efficiency of emergency department physician by transcribing and producing patient medical records in Epic Systems.
  • Accompany the physician into the patient examination area and transcribe patient history into electronic medical records.
  • Trained 4 scribes to accurately and efficiently transcribe medical records, ensuring minimal medical charting deficiencies.
  • Reviewed prior medical records to obtain pertinent medical information to aid provider during patient consultations.
  • Worked one-on-one with cardiologist to create medical records including established patient visits and initial consultations.
  • Utilized electronic medical records program to gather and record all pertinent patient and procedure information.
  • Trained newly hired medical scribes to properly document electronic medical records using appropriate medical terminology.
  • Entered data into electronic medical records as doctors dictated while performing exams on patients.
  • Documented patients' electronic medical records and called consults for providers in the Emergency Department
  • Managed medical records, assisted with patient referrals and obtained third party information.
  • Collaborated directly with Emergency Department providers to develop patients' electronic medical records.
  • Partnered with physicians by managing detailed patient medical records during emergency center visits
  • Maintained accurate medical records and documented patient case history in great detail.
  • Charted all doctor-patient interactions using electronic medical records system for Emergency Department physicians
  • Charted patient-physician encounters in real-time using the Emergency Departments electronic medical records.
  • Complete and present medical records in collaboration with the supervising physician.

Show More

3. Emergency Room

high Demand
Here's how Emergency Room is used in Medical Scribe jobs:
  • Participated in assisting surgical operations, physician-patient clinical communication, patient diagnosis, emergency room patient interaction, and patient dictation.
  • Develop organizational skills and communication skills enabling task completion in high stress situations provided by an Emergency Room atmosphere.
  • Coordinated with emergency room physicians in order to complete accurate charting of emergency room patients.
  • Supported emergency room physicians with patient communication and medical needs.
  • Detailed documentation of emergency room visits using extensive medical vocabulary.
  • Assisted physicians with official medical documentation to improve emergency room efficiency
  • Transcribed Emergency Room patient/doctor interactions and dictated charts.
  • Provided real time documentation for emergency room physicians
  • Cultivated relationships with various emergency room physicians.
  • Exceeded in performing all clerical and information technology functions for a physician in a fast paced, Emergency Room setting.
  • Documented patient's visit and description of illness to the emergency room while staff physician's examine the patient.
  • Assist the emergency room doctors by gathering information about each patient's visit to help ensure a proper diagnosis.
  • Served as a liaison between nursing staff, admissions staff and patients to the emergency room physicians.
  • Transcribe Emergency Room Physician's notes into the computerized EMR (Emergency Medical Record) in real time
  • Obtained knowledge of daily activities in an emergency room, urgent care, and a physician office.
  • Work with multiple emergency room patients, tracking and prioritizing orders and test results for each patient.
  • Completed outbound calls to physicians that were requested to be seen by the emergency room physicians.
  • Documented medical history and exam in patient's medical charts in Level II Emergency Room.
  • Acted as an assistant to the physicians while working in a fast paced emergency room.
  • Anticipate needs of the physician to help keep the flow of emergency room moving.

Show More

4. Physical Exam Findings

high Demand
Here's how Physical Exam Findings is used in Medical Scribe jobs:
  • Accompanied physician during patient consultations and assisted in recording patient history and physical exam findings into the electronic medical record.
  • Accompanied physicians during patient consultations and transcribed patient history and physical exam findings into EMR.
  • Transcribe detailed physical exam findings.
  • Transcribed physician s physical exam findings, diagnostic test results, and admission/discharge plan using EMR in a fast-paced hospital environment
  • Assisted various physicians through documentation of HPI, ROS, and physical exam findings through the EPIC EMR system.
  • Documented physical exam findings along with medical plan of the provider.
  • Accompanied ED physicians and Hospitalists during patient consultations and assisted in obtaining patient's medical history and physical exam findings 3.
  • Complete physician's charts Use EMR program to record HPI, ROS, and physical exam findings

Show More

5. Document Procedures

high Demand
Here's how Document Procedures is used in Medical Scribe jobs:
  • Learned how to document procedures, diagnoses and treatment plan.
  • Document procedures, assessments, consultations and dictations.

Show More

Job type you want
Full Time
Part Time
Internship
Temporary

6. Present Illness

high Demand
Here's how Present Illness is used in Medical Scribe jobs:
  • Chart physician-patient interactions including history of present illness, review of systems, past medical history, physical examinations and procedures.
  • Documented patient's medical history, history of present illness, test results, and medical plan while working beside clinicians.
  • Documented patients' visits including: History of present illness, Review of Systems, and patients' physical examinations.
  • Included history of present illness, review of systems, physical exams, laboratory examination, patient consultations with providers.
  • Document history of present illness, review of systems, and physical exams for each patient evaluated by the physician.
  • Document the patient's history of present illness, review of systems, and physical examination through EHR.
  • Document history of present illness, physical examinations, diagnoses, laboratory tests, assessments, and plans.
  • Obtained and documented information regarding the patients' history of present illness and medical history.
  • Transcribed details of the history of present illness, physical exam, and patient orders.
  • Documented history of present illness, review of systems, and past medical history.
  • Assist physicians by typing up a History of Present Illness during clinic hours.
  • Documented the history of the patient's present illness.
  • Assist the ER physician for organization and efficiency Document History of Present Illness and Physical Exam using flowchart software
  • Experience in Emergency Department Document patient history and present illness Knowledgeable with medical terminology and diseases Follow HIPAA regulations and laws

Show More

7. Diagnostic Tests

high Demand
Here's how Diagnostic Tests is used in Medical Scribe jobs:
  • Performed various diagnostic tests to diagnose any ocular conditions.
  • Transcribed medical information in the form of patient histories, physical exams, diagnostic tests, prescriptions, and treatment plans.
  • Retrieve, analyze, and summarize relevant health history, labs, and diagnostic tests for an accurate HPI.
  • Facilitate the flow of information pertaining to diagnostic tests performed in the department from imaging/lab personnel to the physician.
  • Administered and ordered diagnostic tests, such as x-ray, electrocardiogram and laboratory tests.
  • Assisted clinicians while ordering medications, referrals, and diagnostic tests as needed
  • Ensured accurate and timely placement of all diagnostic tests for patients.

Show More

8. Lab Results

high Demand
Here's how Lab Results is used in Medical Scribe jobs:
  • Follow along with a physician and keep track of all of his interactions with patients as well as pertinent lab results.
  • Assisted practitioners in navigating the Electronic Health Record (EHR) and locating information such as test and lab results.
  • Paged consults, made phone calls, and updating the residents of any pertinent imaging or lab results.
  • Gained insight into the basics of ordering tests, interpreting lab results and reading X-rays.
  • Complete medical charts and transcribe any lab results, x-rays, or other examinations.
  • Updated lab results in patients' medical record as indicated by the provider.
  • Prioritized the physician's time by bringing critical lab results to his/her attention.
  • Scribe for different physicians, Pull up recent lab results and medications.
  • Transcribed lab results and treatment on both high and low acuity patients.
  • Dictated all patient history, physical exam, and various lab results.
  • Monitored the duration of basic lab results and screening procedures.
  • Update providers when I notice abnormal lab results.
  • Input of medical lab results and images.
  • Monitored the progress of lab results.
  • Filed lab results with charts.
  • Document procedures, lab results, dictated radiographic impressions and any other pertinent information related to patient care.
  • Utilized extensive amounts of medical terminology and abbreviations Effectively interpreted lab results, X-Rays, and prior medical history
  • Document procedures, lab results, radiographic impressions and any other information pertaining to the patient's encounter in the ED.
  • Document procedures, lab results, dictated radiographic impressions made by physician in Emergency Department and clinical settings.
  • Record procedures, lab results, dictated radiographical impressions, and billing information made by the supervising physician.

Show More

9. Physician-Patient Encounters

high Demand
Here's how Physician-Patient Encounters is used in Medical Scribe jobs:
  • Specialize in charting physician-patient encounters during medical examinations.
  • Chart physician-patient encounters in real-time.

Show More

10. HPI

high Demand
Here's how HPI is used in Medical Scribe jobs:
  • Inputted full exam notes which included HPI's, assessments, vitals, treatments, procedures, and billing codes.
  • Work with ER Physicians on all documentation, HPI'S and orders throughout each shift.
  • Document HPI and physical exams.
  • Write up patient's HPI, Medical record, record lab, x-rays, CT results, etc.
  • Document orders and procedures for each treated patient.Create and maintain a patient's HPI
  • Review nurses' notes and (if any) past visit documentation for pertinent HPI and background information.

Show More

11. Lab Tests

high Demand
Here's how Lab Tests is used in Medical Scribe jobs:
  • Document diagnoses, lab tests, diagnostic studies, medications, procedures and follow-up instructions.
  • Transcribed all ancillary test results, including any lab tests and imaging tests.
  • Transcribed results of diagnostic studies and lab tests onto patient's chart.
  • Obtained and interpreted appropriate lab tests.
  • Transcribed test results,lab tests, imaging tests, ECG s and ABG s. Charted patient history and physical exams.
  • Transcribed all test results and interpretations, including lab tests, imaging tests, and ECGs.

Show More

12. Treatment Plans

high Demand
Here's how Treatment Plans is used in Medical Scribe jobs:
  • Served as a liaison and Spanish translator between patients and physicians to assist patients with the understanding of their treatment plans.
  • Worked as a personal medical scribe helping the physician to see patients, discussing work-ups, treatment plans, and diagnoses.
  • Assist physicians with EMR for patients.-Gather Patient History during visit to Geriatric Office-Assisted with providing treatment plans and care to patients
  • Generate individualized asthma action plans and food allergy emergency treatment plans for patients and save within their EHR chart.
  • Complete real-time medical coding during the patient encounter and utilize existing templates to document treatment plans and patient instructions.
  • Document all diagnoses, treatment plans, prescriptions, and discharge information.
  • Dictated discharge summaries, treatment plans and after care instructions.

Show More

13. Patient S

average Demand
Here's how Patient S is used in Medical Scribe jobs:
  • Documented consultations between physicians, procedures, and any other information pertaining to patient s encounter.
  • Assisted physician in electronically documenting and charting patient s visit summary.
  • Managed hypothetical patient scenario training for chart accuracy.
  • Participated in improving patient satisfaction.
  • Maintain efficient work flow and speed to decrease patient visit times and increase the physician productivity and patient satisfaction scores.
  • Improved patient satisfaction, by ensuring every patient s medical referrals are made prior to departure from the office.
  • Send prescribed medications via Epic or call in prescriptions to the patient s pharmacy per the provider s request.
  • Transcribe the patient's plan and assessments into patient s EHR chart as dictated by the provider.
  • Organized, monitored and recorded patient status, medications, laboratory, EKG and imaging results.
  • Work directly with physician s to document patient encounters throughout a patient s treatment.
  • Created patient s histories, review of systems and recorded physical examinations for physicians.
  • Documented the entire patient stay and assisted the physician with lab/medication/plan of care.
  • Work to ensure an accurate and complete medical record for every patient seen.
  • Follow up with the hospital s radiation and laboratory for patient s results.
  • Maintained charts with medical procedures, consultations, and patient status.
  • Observe and document any relevant issues to the patient s illness.
  • Document patient surgical procedure note for surgeon on call.
  • Monitor patient status and update physician of any changes.
  • Reconcile patient medications within the patient s EHR.
  • Assist physicians with documentation of patient encounters in order to improve patient satisfaction and physician productivity

Show More

14. Hipaa

average Demand
Here's how Hipaa is used in Medical Scribe jobs:
  • Demonstrated an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.
  • Managed sensitive and confidential materials such as patient health records following HIPAA regulations.
  • Gained experience regarding protecting patient privacy and working within HIPAA guidelines.
  • Demonstrated knowledge of HIPAA Privacy by appropriately handling patient information.
  • Maintained patient confidentiality and followed HIPAA guidelines.
  • Partnered with clinical professionals to coordinate patient care while exercising a high degree of professionalism and confidentiality in compliance with HIPAA.
  • Experience in maximizing reimbursement, mitigating cost, preventive care, meaningful use(HITECH Act), and HIPAA compliance.
  • Trained on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding.
  • Maintained patient confidentiality and data integrity in accordance with Health Insurance Portability and Accountability Act (HIPAA).
  • Presented myself in a profession manner, adhering to all medical and professional protocols and respecting HIPAA laws.
  • Experience with medical terminology, components of a medical record, EPIC EMR, and HIPAA compliance.
  • Undergo continued education on technology, legal, HIPAA, billing, coding, and regulatory compliance.
  • Performed all duties while adhering to HIPAA policies as well as hospital sanitation guidelines.
  • Complied with HIPAA and handled confidential patient information on a daily basis.
  • Provided a competent understanding of the HIPAA standards and patient confidentiality.
  • Certified training in HIPAA and Epic medical documentation software.
  • Ensured complete accuracy and HIPAA compliance at all times.
  • Understand and observe legal concepts such as HIPAA
  • Trained new employees and ensured HIPAA compliance.
  • Maintained HIPAA and HITECH confidentiality throughout employment.

Show More

15. Radiology

average Demand
Here's how Radiology is used in Medical Scribe jobs:
  • Transcribe patient orders including laboratory tests, radiology tests, medications, among other medical related requests.
  • Monitor radiology and laboratory results and report abnormal findings to the doctor.
  • Recorded patient orders including laboratory tests, radiology tests, and medications.
  • Notified clinicians of resulted laboratory and radiology orders.
  • Access and document laboratory results and radiology findings.
  • Call laboratory and Radiology when needed.
  • Documented radiology and lab reports.
  • Transcribe patient orders, including laboratory and radiology tests, medication, etc - Document any procedures performed by the physician.
  • Update charts with labs, radiology reports and progress notes and updating physicians/practitioners of the results to expedite the patient flow.
  • Coordinate departmental resources regarding required tests, create hospital orders, schedule radiology tests, and track and review all results.
  • Keep track of recording patient's lab and radiology results and notify physicians when they are ready to be reviewed.
  • Documented procedures, reasons and results of patients orders such as lab tests, radiology tests and medications.
  • Document patient history, physical exam, radiology and imaging results, procedures, and physician consultations.
  • Provided advanced physician support by reporting lab results, radiology findings, and pertinent patient medical histories.
  • Fast pace ER, keep Physician informed when radiology, labs, and critical results come back.
  • Documented chief complaint, past medical history, review of systems, exam, and radiology reports
  • Transcribed lab and radiology test results and tracked test progress on patients' charts for physicians.
  • Work alongside providers to help input labs, radiology, and other information into patients charts.
  • Trained and experienced in T-System charting and EMR including order entry and digital radiology interface.
  • Transcribe patient orders including laboratory tests results, radiology test findings, medications, allergies.

Show More

16. Physician Assistants

average Demand
Here's how Physician Assistants is used in Medical Scribe jobs:
  • Communicated with physicians and physician assistants concerning charting of patient encounters and alerted them to incoming laboratory and imaging results.
  • Experienced how different physician assistants and physicians interact with patients and gained understanding of physician assistant and physician relationship.
  • Assisted emergency department physicians and physician assistants in preparing electronic medical charts for multiple patients.
  • Communicated successfully with a wide variety of professionals including Physicians, Physician Assistants, Nurses, and ER technicians.
  • Worked directly with doctors and physician assistants to provide fast and accurate patient documentation for 75-150 patients daily.
  • Coordinate care between nurses, emergency medicine physicians, physician assistants, and techs.
  • Followed Physicians and Physician Assistants while they treated patients.
  • Documented charts for Physicians as well as Physician Assistants.
  • Collaborated with physicians and physician assistants to insure accurate medical chart documentation.
  • Work directly with doctors, physician assistants, and nurses of Regions Hospital and Lakeview Hospital Emergency Departments.
  • Assist attendings, fellows, residents, and physician assistants with accurate patient documentation.

Show More

17. EKG

average Demand
Here's how EKG is used in Medical Scribe jobs:
  • Perform and record results of point of care lab tests such as Urinalysis, EKG's, and Rapid Strep tests.
  • Assisted physicians in inputting patient information by interpreting EKG's, lab results, patient assessments, and communicating with staff.
  • Order labs and imaging tests as instructed by the doctor and record physician's interpretation of X-Rays and EKG's.
  • Collected patient's vital signs and performed an EKG during their clinic visit.
  • Reviewed chest x-rays, EKG's, CT's, and interpreted lab results.
  • Read abnormal lab values, chest x-rays, and EKG's
  • Assisted in training new scribes to the department Performed tasks such as EKG filling and consults with other physicians as necessary
  • Assist in advanced work flow by updating providers when X-ray, EKG, and lab results are complete.
  • Perform EKGs, urinalysis, prime IVs, and swab for cultures.
  • Record findings and organize EKGs that correspond to each patient.
  • Record physician interpretations of X-rays and EKGs.
  • Read and document all results for tests being done (i.e EKGs, X-Rays) per patient.
  • Worked alongside two physicians in the ED to document patient history, physical exams, imaging, and EKGs.
  • Submitted and documented EKGs, MRIs, and all lab workups.
  • Order and read lab tests, x-rays, MRIs, Ultrasounds, and EKGs.
  • Performed Ekg's Abi's, Pft's, and vitails.

Show More

18. ROS

average Demand
Here's how ROS is used in Medical Scribe jobs:
  • Documented HPI, PMH, ROS, vital statistics, and bedside physical examinations on EPIC.
  • Documented HPI, PMH, ROS, and bedside physical examination on ECW in real time.
  • Transcribed information into a proper medical note including HPI, ROS, and exam findings.
  • Demonstrated sufficient skills in HPI, ROS, exam, and assessment documentation.
  • Utilized the software programs Emergency Medical Software (EMS), and Microsoft.
  • Documented the Review of Systems (ROS) and physical examination.
  • Experience with full Microsoft Office productivity suite.
  • Assisted with ultrasound or fluoroscopy guided injections.
  • List all proper diagnoses and symptoms as well as follow up instructions and proscriptions as dictated by the physicians.
  • Collect and count weekly mold and pollen counts in the Roseville area.
  • Record ROS, re-eval, f/u.
  • Take detailed medical notes for a neurosurgeon through Centricity Data entry of physical therapy billing codes
  • Summer 2012 Medical Scribe: Assisted Dr. Angel R. Chinea, Neurologist, in Multiple Sclerosis & Migraine Clinics.
  • Documented HPI/ROS/PE/diagnostic differentials/course and progress notes/consultations/PMHx, SHx, FHx, Rx list.
  • Documented HPI, PMH, ROS and bedside physical examination in EPIC.

Show More

19. Patient Orders

average Demand
Here's how Patient Orders is used in Medical Scribe jobs:
  • Transcribed patient orders including laboratory tests, imaging, medications ordered, and procedures administered.
  • Transcribed physician-patient encounters in real-time and input patient orders and exam results.
  • Transcribe patient orders including laboratory tests

Show More

20. Patient Examination Room

average Demand
Here's how Patient Examination Room is used in Medical Scribe jobs:
  • Accompanied emergency department physicians into patient examination room to accurately document the encounter.
  • Accompany physician into the patient examination room in order to transcribe the patient's history and physical exam.
  • Accompanied provider(s) into patient examination room to accurately and efficiently document the encounter.

Show More

21. Providers

average Demand
Here's how Providers is used in Medical Scribe jobs:
  • Worked closely with physicians and mid-level providers in a high-acuity, high-volume Emergency Department.
  • Participate in patient encounters and interviews alongside physicians and other medical providers.
  • Accompany providers and assist with documentation of the electronic medical record.
  • Develop and maintain a mutually respectful working relationship with all providers.
  • Provide non-clinical assistance to medical providers in multiple departments 2.
  • Communicated with providers based on an understanding of medical terminology.
  • Write and review medical documentation for providers.
  • Prepared reports for medical providers.
  • Transcribed medical charting for Providers.
  • Assist the physician with printing information from the chart as needed for admission or communication with other health care providers.
  • Delivered the pinnacle of efficient and patient focused care that alleviated the stress felt by the providers and the patients.
  • Maintain medical chart efficiency and organization to increase ED patient flow by allowing providers to focus on providing patient care
  • Interact with Emergency Department physicians, nurses, residents, consults, and mid-level providers for adequate patient care.
  • Worked closely with providers to document patient visit with attention to detail for accurate and comprehensive patient care.
  • Work alongside medical providers in the emergency room inputting information into patients' medical charts in real time.
  • Monitored the return of clinical and imaging diagnostics and report their status to the providers as needed.
  • Update providers of lab and imaging results ordered on the patient to help better their work flow.
  • Ensured providers were more efficient and accurate by developing an understanding of ICD-9 guidelines and EHR capabilities.
  • Assisted providers with procedures, such as cast applications, incision and drainage, and fracture reductions.
  • Worked side-by-side with health care providers and assisted with entering results of Pulmonary Function Tests.

Show More

22. Data Entry

average Demand
Here's how Data Entry is used in Medical Scribe jobs:
  • Prepared and sent all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
  • Specialize in medical data entry into a paper or electronic medical record system.
  • Documented medical data entry into the electronic medical record system.
  • Prepared detailed data entry and facility-specific procedures.
  • Specialized in billing and coding, performed medical data entry for electronic medical system, and assisted physician throughout entire shift.
  • Specialized in medical data entry electronic medical record system, in this case EPIC.
  • Prepare each patient chart for data entry for the upcoming week.
  • Assisted emergency room physician with data entry for patient record.
  • Prepare patients' charts for data entry.
  • Experience with medical data entry systems.
  • Dictate notes for providers on internal medicine visits Performed various administrative duties, including data entry and document preparation.
  • Specialized in medical data entry into an electronic medical record system and instituted efficient workflow process.

Show More

23. Vital Signs

average Demand
Here's how Vital Signs is used in Medical Scribe jobs:
  • Documented clinical findings, reviews of systems, past medical history, vital signs and demographic information during patient examinations.
  • Measure and document vital signs of patients including: weight, height, temperature, blood pressure, and pulse.
  • Update vital signs, laboratory results, and print and file doctors' notes in patients' charts.
  • Perform duties of a Medical Assistant by rooming patient, taking vital signs, and counting medication.
  • Conduct vital signs: weight, blood pressure, pulse, temperature, respiration and record information.
  • Assisted Emergency Room doctors with patient documentation and laboratory test ordering; took vital signs and patient intake
  • Take vital signs and sign up patients for medical trials and MD Revolution as needed.
  • Interview patients, Obtain medical information (vital signs), Prepares them for examination.
  • Escorted patients from waiting room to exam room, preformed vital signs exams.
  • Entered vital signs and keep track of lab values.
  • Obtain patient medical history and vital signs.
  • Trained new scribes to record patient's vital signs and medical history using the eClinicalWorks program.
  • Checked in patients, triaging vital signs, and documenting complaints.
  • Record vital signs Complete documentation for ER physician's final approval.

Show More

24. Medical Decision

average Demand
Here's how Medical Decision is used in Medical Scribe jobs:
  • Anticipate medical decision-making and procedures by using critical thinking skills.
  • Document patient history of present illness, complaints, review of systems, physical exam, and medical decision making.
  • Assist the MD/DO/PA/NP with any medical decision making, procedures, and charting.
  • Observed medical decision making at various stages.
  • Discussed differential diagnoses, pertinent diagnostic studies and medical decision making rationale with physicians.
  • Gained an understanding of medical terminology and the medical decision-making process of healthcare professionals.
  • Communicated with healthcare providers to validate and verify medical decision making.
  • Collaborated with ED physicians on charting real time patient care and medical decision making.
  • document reason for patient visit, physical exam findings, medical decision making process.

Show More

25. Medical Procedures

average Demand
Here's how Medical Procedures is used in Medical Scribe jobs:
  • Ensured proper coding of medical procedures for insurance submission and documentation.
  • Observed medical procedures while documenting.
  • Entered patient's medical history and physical exam, medical procedures, and diagnostic test results into an electronic health record.
  • Prepared incoming patients for lacerations, abscess drainage, X-Ray and any additional medical procedures.
  • Followed the physician and document all medical procedures and interactions with patients.
  • Record medical procedures, patient history, and any other circumstances.
  • Worked with McKesson EHR healthcare software, medical terminology, anatomy/physiology, pharmacology, hospital codes/standards, and various medical procedures.

Show More

26. Phone Calls

low Demand
Here's how Phone Calls is used in Medical Scribe jobs:
  • Make and receive phone calls; generate referrals, recommendations, and letters for the patient on behalf of the provider.
  • Assisted Physician in ranking patient priority, answering consult phone calls, and scanning and entering data into records system.
  • Completed administrative functions ranging from note taking, monitoring of physician support services, phone calls and clerical tasks.
  • Answer phone calls, file paperwork, complete forms, use EMR to chart patient encounters.
  • Coordinate referrals, prepare operative reports, make phone calls and perform other clerical tasks.
  • Make and receive phone calls on behalf of provider(s).
  • Assist physicians with patients, answer phone calls, chart patient's visit
  • Performed dictation, faxing, outbound phone calls and clerical tasks.
  • Provided customer service through answering phone calls and scheduling appointments.
  • Answer telephone calls in a professional manner, appropriately transfer calls, responds to inquiries and interpret messages.

Show More

27. Discharge Instructions

low Demand
Here's how Discharge Instructions is used in Medical Scribe jobs:
  • Documented diagnosis and discharge instructions and delivered prescriptions and discharge documents to nurses.
  • Organized appropriate follow-up appointments, discharge instructions and hospital admissions.
  • Assist in preparation and organization of patient discharge instructions.
  • Entered the patient's disposition and discharge instructions as directed by the physician, as well as updating their medical history.
  • Assisted in disposition of patient, whether discharged or admitted, including discharge instructions, admission orders and prescription forms.!
  • Assist the ED MD in entering the clinical impression and admission information or discharge instructions.
  • Managed patient discharge paper work and provided discharge instructions to patients and families.
  • Document test results, consultations, medications and discharge instructions.
  • discharge instructions, patient education materials
  • Discharge instructions/Admission information (ex.
  • Accompanied patients to the doctorRead discharge instructions.
  • Prepared discharge instructions and and followup paperwork for the patient prior to their departure from the ED.

Show More

28. Hippa

low Demand
Here's how Hippa is used in Medical Scribe jobs:
  • Complied with HIPPA privacy and various government laws regarding confidential information.
  • Educated trainees on use of EPIC computer system and HIPPA regulations.
  • Follow HIPPA, compliance, billing, and coding regulations.
  • Follow all medical regulations and HIPPA policies.
  • Compiled with HIPPA rules and regulations.
  • Adhere to the HIPPA Code of Conduct.
  • Maintained strictest confidentiality and adhered to all HIPPA guidelines /regulations.
  • Completed classroom training and assessments in medical terminology, relevant pathophysiology, ER flow, medical documentation, and HIPPA policies.
  • Maintain confidentiality and privacy in respect to HIPPAA Organizational ability to maintain and coordinate multiple documentation and formsrelated to patient care.

Show More

29. Cerner

low Demand
Here's how Cerner is used in Medical Scribe jobs:
  • Assist ER Physicians by keeping notes of all actions and interactions with patients, using Cerner software
  • Recorded patients' review of systems, medical histories, and chief complaints using Cerner EMR.
  • Navigate electronic health records, using Cerner and Epic software programs.
  • Utilized Cerner electronic health record system to transcribe patient charts.
  • Prepared detailed accounts of doctor-patient encounters, using Cerner EHR.
  • Operated Cerner, IDX, Edoma, & APS tracking systems.
  • Used Cerner/Firstnet and Tsheet system for documentation.

Show More

30. Meditech

low Demand
Here's how Meditech is used in Medical Scribe jobs:
  • Prepared medical charts for dictation Ordered diagnostics through MEDITECH
  • Shadow Emergency Room physicians and provide detailed documentation assistance in real-time using Meditech Software for up to 40-50 patients per shift.
  • Advanced experience with DocShuttle, Microsoft Word, Excel, PowerPoint, Outlook, WordPerfect, MEDITECH and eClinicalWorks.
  • Maintain a list of active patients in Meditech EHR to help the provider remain organized.
  • Established proficiency with two electronic medical record (EMR) systems- EPIC and Meditech.
  • Processed patient admissions in Meditech EHR.
  • Look for procedure reports and other documents in different EMR systems such as Intergy, Athena, and Meditech.

Show More

31. Healthcare

low Demand
Here's how Healthcare is used in Medical Scribe jobs:
  • Provide accurate, on-site, real-time medical documentation of hundreds of patient encounters using NextGen Healthcare electronic medical record system.
  • Trained in medical documentation to help healthcare providers during exam visits.
  • Collaborated with healthcare professionals to provide excellent patient care and satisfaction.
  • Communicate effectively between a variety of healthcare professionals.
  • Communicated effectively with healthcare providers.
  • Work with Physicians, PA's, NP's, and other healthcare providers documenting medical notes.
  • Expedited the flow of the emergency department and increased accurate billing by writing patient charts for healthcare providers
  • Facilitated the healthcare needs of visiting patients and health care professionals according to company policies.
  • Record provider's consultations with other healthcare providers, patients and family members.
  • Document procedures and treatments performed by the physician or any other healthcare professional.
  • Tracked lab and x-ray results and patient evaluation data to healthcare professionals.
  • Referred to and consulted with physicians and other healthcare providers.
  • Advised healthcare providers once lab and imaging results were received.
  • Gained firsthand exposure to the healthcare field.
  • Observed direct physician and healthcare staff interaction.
  • Edit patient charts for healthcare providers.
  • Gained experience in a fast-paced healthcare environment and learned how to work well with healthcare staff as well as patients.
  • Establish and pilot a new scribe program for the Hannibal Regional Healthcare System.
  • Established best-practices workflows and fostered a productive client relationship as one of the programs inaugural employees at Carolinas HealthCare System.

Show More

32. Patient Consultation

low Demand
Here's how Patient Consultation is used in Medical Scribe jobs:
  • Accompanied medical professional during patient consultations and completed electronic medical record in EPIC.
  • Accompanied multiple emergency room physicians during patient consultations.
  • Accompany physician during patient consultations.
  • Document up to 45 patient consultations per shift.

Show More

33. Pertinent Information

low Demand
Here's how Pertinent Information is used in Medical Scribe jobs:
  • Accompanied physicians on medical examinations and was dictated the pertinent information of the doctor-patient interaction.
  • Recorded all pertinent information to meet diagnostic and legal requirements.
  • Developed keen listening skills and focus to capture pertinent information from live patients.
  • Documented pertinent information about the patient for the hospital.
  • Assisted Physicians with the administrative aspects of patient care Documented in detail all pertinent information gathered during patient's visit.
  • Document the patient history, physical exam, radiographic findings, and other pertinent information when assisting the physician.

Show More

34. Internal Medicine

low Demand
Here's how Internal Medicine is used in Medical Scribe jobs:
  • Organized and transcribed results for patient's laboratory tests, medications and imaging studies in Internal medicine and Emergency Department 2.
  • Work full-time with physician board certified in internal medicine and pediatrics as he treats patients on a daily basis.
  • Work closely with Internal Medicine Physicians by interpreting past medical history, and plan for care during admission.
  • Carried out established protocols and competently completed routine clinical and administrative tasks for internal medicine office with 10 physicians.
  • Assisted physicians of Internal Medicine with patient care and organization tasks including education and chart and scheduling management.
  • Coordinated physician and hospital communication for board certified pulmonary, sleep, hospital and internal medicine physicians.

Show More

35. New Scribes

low Demand
Here's how New Scribes is used in Medical Scribe jobs:
  • Oversee and train new scribes on-site, facilitating communication among scribes and enforcing new protocols.
  • Trained new scribes, overseeing their knowledge of medical terminology and charting elements.
  • Assess skills of new scribes and offer proper direction when needed.
  • Train new scribes in ED and during ED simulation course.
  • Coordinated with HQ in training and assessment of new scribes.
  • Trained new scribes on proper medical documentation and EMR.
  • Practiced leadership and communications skills while training new scribes.
  • Trained new scribes according to hospital and company policies.
  • Assisted ER physicians in documentation of patients' medical histories, organization of charts and laboratory results Trained new scribes
  • Train new scribes, audit current scribes and train new physicians who have never worked with scribes.

Show More

36. Medical Staff

low Demand
Here's how Medical Staff is used in Medical Scribe jobs:
  • Interacted extensively with medical staff and personnel on daily basis.
  • Furthered working relationships with the medical staff to produce optimal health care and efficiency.
  • Consulted other physicians or medical staff upon request of the medical provider.!
  • Act as a mediator between the patient and the medical staff.
  • Communicated with medical staff to ensure timely and appropriate patient care.
  • Worked as a vital member of the ER medical staff.

Show More

37. Diagnostic Studies

low Demand
Here's how Diagnostic Studies is used in Medical Scribe jobs:
  • Demonstrated proficiency in recording patient's symptoms, history, physical exam, laboratory, diagnostic studies, and diagnosis.
  • Inform provider(s) when diagnostic studies are completed, prepare for review, and document in EMR.
  • Order Diagnostic Studies per Clinicians request.
  • Dictate and record patient care Prepare diagnostic studies for review including MRI, CT, EMG, etc.

Show More

38. Nurse Practitioners

low Demand
Here's how Nurse Practitioners is used in Medical Scribe jobs:
  • Transcribed visits with licensed Medical Doctors and Nurse Practitioners.
  • Worked closely with Emergency medical physicians, physician s assistants and nurse practitioners at Ellis Hospital in Schenectady, New York.
  • Worked with physicians, physician assistants, and nurse practitioners as part of a unified health care team.
  • Serve as a medical scribe to physicians, physician assistants, nurse practitioners and residents.
  • Assist physicians, nurse practitioners, and physician assistants.
  • Scribed for medical doctors, physicians assistants, and nurse practitioners at Children's Hospital.

Show More

39. Follow-Up Information

low Demand
Here's how Follow-Up Information is used in Medical Scribe jobs:
  • Documented all diagnoses, treatment plans, future labs, imaging, and referrals, as well as the follow-up information.
  • Documented procedures, diagnoses, treatment plans, prescription medications, patient instructions, and follow-up information.
  • Document procedures performed, treatment plans, prescriptions given, and follow-up information in electronic medical record.

Show More

40. Medical Professionals

low Demand
Here's how Medical Professionals is used in Medical Scribe jobs:
  • Demonstrated ability to multitask in support of numerous medical professionals.
  • Created relationships with a variety of medical professionals in differing fields of study.
  • Work with doctors and other medical professionals to help patients.

Show More

41. Patient Interviews

low Demand
Here's how Patient Interviews is used in Medical Scribe jobs:
  • Accompany main physician during patient interviews and examinations.
  • Transcribe doctor/patient interviews in an emergency room setting.
  • Accompanied physician upon patient interviews and examinations.

Show More

42. Accurate Documentation

low Demand
Here's how Accurate Documentation is used in Medical Scribe jobs:
  • Work with medical assistant to ensure accurate documentation of all interactions between physician and patient.
  • Ensured complete and accurate documentation of Emergency Department visits according to standards.
  • Provide fast and accurate documentation for the physician in real time.
  • Unload provider's trouble of documentation of patient's ED visit Improve patient quality of care Provide accurate documentation of patient charting

Show More

43. Icd-10

low Demand
Here's how Icd-10 is used in Medical Scribe jobs:
  • Answer PhonesSchedule PatientsAnswer Incoming CallsUpdate Patients Demographics Verify Medical InsuranceFile Insurance ClaimsOrder Contact LensInventory Contact LensScribe For OptometristICD-10 Coding
  • Practiced medical terminology and ICD-10 coding.
  • Experienced in ICD-10 code billing and the collection of co-pays and deductibles.
  • Work directly with physician to provide adequate documentation with ICD-10 coding standards.
  • Enter ICD-10 codes for billing purposes.
  • Experience with ICD-9-CM, ICD-10-CM, CPT codes, and billing transactions.
  • Enter ICD-10 CM and CPT codes into EHR.
  • Continued learning of clinical skills and medical knowledge specific to orthopedics Learned how to code and bill for ICD-10
  • Developed knowledge of ICD-10 and ICD-9 chart documentation and coding -Strong Medical Terminology -Developed typing speed of 70WPM with 100% accuracy

Show More

20 Most Common Skill for a Medical Scribe

Patient Care27.7%
Medical Records19%
Emergency Room14.1%
Physical Exam Findings8.4%
Document Procedures7.6%
Present Illness2.5%
Diagnostic Tests2.5%
Lab Results2.5%

Typical Skill-Sets Required For A Medical Scribe

RankSkillPercentage of ResumesPercentage
1
1
Patient Care
Patient Care
24.7%
24.7%
2
2
Medical Records
Medical Records
16.9%
16.9%
3
3
Emergency Room
Emergency Room
12.6%
12.6%
4
4
Physical Exam Findings
Physical Exam Findings
7.5%
7.5%
5
5
Document Procedures
Document Procedures
6.7%
6.7%
6
6
Present Illness
Present Illness
2.2%
2.2%
7
7
Diagnostic Tests
Diagnostic Tests
2.2%
2.2%
8
8
Lab Results
Lab Results
2.2%
2.2%
9
9
Physician-Patient Encounters
Physician-Patient Encounters
1.7%
1.7%
10
10
HPI
HPI
1.5%
1.5%
11
11
Lab Tests
Lab Tests
1.3%
1.3%
12
12
Treatment Plans
Treatment Plans
1.2%
1.2%
13
13
Patient S
Patient S
1.2%
1.2%
14
14
Hipaa
Hipaa
1.1%
1.1%
15
15
Radiology
Radiology
1.1%
1.1%
16
16
Physician Assistants
Physician Assistants
1.1%
1.1%
17
17
EKG
EKG
1.1%
1.1%
18
18
ROS
ROS
1%
1%
19
19
Patient Orders
Patient Orders
1%
1%
20
20
Patient Examination Room
Patient Examination Room
0.9%
0.9%
21
21
Providers
Providers
0.7%
0.7%
22
22
Data Entry
Data Entry
0.7%
0.7%
23
23
Vital Signs
Vital Signs
0.7%
0.7%
24
24
Medical Decision
Medical Decision
0.7%
0.7%
25
25
Medical Procedures
Medical Procedures
0.6%
0.6%
26
26
Phone Calls
Phone Calls
0.6%
0.6%
27
27
Discharge Instructions
Discharge Instructions
0.6%
0.6%
28
28
Hippa
Hippa
0.5%
0.5%
29
29
Cerner
Cerner
0.5%
0.5%
30
30
Meditech
Meditech
0.5%
0.5%
31
31
Healthcare
Healthcare
0.5%
0.5%
32
32
Patient Consultation
Patient Consultation
0.5%
0.5%
33
33
Pertinent Information
Pertinent Information
0.5%
0.5%
34
34
Internal Medicine
Internal Medicine
0.4%
0.4%
35
35
New Scribes
New Scribes
0.4%
0.4%
36
36
Medical Staff
Medical Staff
0.4%
0.4%
37
37
Diagnostic Studies
Diagnostic Studies
0.3%
0.3%
38
38
Nurse Practitioners
Nurse Practitioners
0.3%
0.3%
39
39
Follow-Up Information
Follow-Up Information
0.3%
0.3%
40
40
Medical Professionals
Medical Professionals
0.3%
0.3%
41
41
Patient Interviews
Patient Interviews
0.3%
0.3%
42
42
Accurate Documentation
Accurate Documentation
0.3%
0.3%
43
43
Icd-10
Icd-10
0.3%
0.3%

43,763 Medical Scribe Jobs

Where do you want to work?