
Healthcare Clinical Documenter
1 week ago
Medical Documentation Specialist
A medical scribe plays a crucial role in the healthcare industry by documenting clinical interactions in real-time. This enables healthcare providers to focus on patient care, rather than administrative tasks.
Key Responsibilities:- Accurately document patient encounters using Electronic Medical Records (EMRs).
- Capture comprehensive patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Update and maintain charts, medication lists, allergies, and problem lists.
- Assist with administrative tasks such as templating notes and handling visit summaries.
- Review prior records to provide context for current visits.
- Maintain communication with providers for clarification and accuracy of documentation.
- Ensure all documentation meets HIPAA standards and is clinically and legally sound.
- Demonstrate strong attention to detail and discretion when handling sensitive patient data.
- Excellent verbal and written English communication skills.
- At least 1–2 years of experience as a medical scribe or in a clinical documentation role.
- Familiarity with medical terminologies and clinical workflows.
- A healthcare-related degree is highly preferred.
- Proficiency in Google Workspace and/or Microsoft Office.
- Experience with EMRs is beneficial.
- HIPAA Certification is desirable.
- Fast and accurate typing skills.
- Strong attention to detail.
- Organized and highly focused.
- Open to working night shifts.
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