What Does A Medical Scribe Do?

WHAT DOES A MEDICAL SCRIBE DO?

Published: Dec 01, 2025 - The Medical Scribe accurately documents all visit elements as stated by the practitioner, enters comprehensive patient information into the electronic health record, and ensures each entry is properly authenticated. This role involves locating and retrieving prior notes, test results, and other clinical data while assisting the practitioner in navigating the medical record and responding to messages as directed. The Scribe also supports care delivery by conducting practitioner-requested research, maintaining timely and detailed encounter documentation, and facilitating smooth access to critical patient information.

A Review of Professional Skills and Functions for Medical Scribe

1. Medical Scribe Job Summary

Clinical Documentation: Escort the physician to document the events in the history and physical exam, and document accurately during the physician examination.
Symptom Recording: List all symptoms and diagnoses, including laboratory tests, medication orders, treatments, etc.
Procedure Documentation: Document all procedures performed by the physician.
Patient Verification: Verify patient information by interviewing the patient, recording medical history, and confirming the purpose of the visit.
Post-Treatment Testing: Perform post-treatment physical tests, such as taking blood pressure and body temperature, and record the patient's history summary.
Record Security: Secure patient information and maintain patient confidence by completing and safeguarding medical records.
Workplace Safety: Maintain a safe, secure, and healthy work environment by establishing and following standards and procedures, and complying with legal regulations.
Practice Compliance: Serve and protect the practice by adhering to professional standards, policies and procedures, and federal, state, and local requirements.

2. Medical Scribe Accountabilities

Encounter Transcription: Listen to the recordings of the provider/patient encounter and transcribe the history, review of symptoms, past histories, physical exam, laboratory, and radiological results as dictated by the provider.
Template Selection: Select the appropriate template from the computer system.
Clinical Documentation: Document history and physicals (H&Ps), progress notes, and discharge summaries.
Provider Action Recording: Record the actions (physical exam and procedures) and words of the provider.
After-Care Documentation: Record discharge and after-care instructions in the medical record as directed by the provider.
Spelling Accuracy: Ensure complete and accurate spelling on documentation of the patient encounter, and notify the provider if more information is needed for documentation.
Chart Elements Entry: Record any other elements in the medical chart per the provider’s preference.
Preference Review: Review provider preferences to ensure documentation meets the provider's expectations.
Turnaround Compliance: Ensure documentation is completed within the contractual turnaround time obligation.
Objective Charting: Avoid interjecting personal observations or impressions when charting in the medical record.

3. Medical Scribe Functions

Record Preparation: Prepare and assemble medical record documentation and charts for physicians.
EMR Transcription: Enter the patient room with the physician during a patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
Compliance Attestation: Ensure medical record compliance by self-documentation attestation to include scribe name, title, doctor working for, and specific date and time entry.
Patient Record Updating: Update patient history, physical exam, and other pertinent health information in the patient record.
Documentation Submission: Prepare and send all documentation to the physician for review and approval via authentication of detailed data entry and facility-specific procedures.
Lab Monitoring: Monitor the duration of basic lab results and screening procedures.
Policy Compliance: Comply with hospital and ProScribe policies, including those relating to HIPAA and the Joint Commission.
Attendance Reliability: Maintain regular and reliable attendance at the assigned facility.
Clerical Support: Perform other clerical duties and tasks to improve provider productivity and clinic workflow.

4. Medical Scribe Job Description

Medical Transcription: Transcribe medical reports, summaries, office visit notes, and other medical documents from recorded messages from health care providers.
Document Submission: Provide online copies of transcribed documents to physicians or other providers for review and signature, making corrections or changes as noted.
Language Accuracy: Be familiar with proper grammar, spelling, and sentence structure as well as medical jargon and abbreviations for accuracy.
Administrative Reporting: Prepare correspondence, summaries, research, and other administrative reports not directly related to patient care in order to assist the medical team.
Transcription Equipment Use: Work with transcription equipment, including speech recognition equipment, word processing and computer software, medical references, and other technologies.
Confidentiality Compliance: Maintain strict adherence to patient confidentiality according to provider standards and government regulations.
Quality Assurance: Review transcription documents for quality assurance and precision to spot and correct any errors that could impact patient care and medical liability.
EHR Data Entry: Create templates and enter data into electronic health record (EHR) systems for updated record keeping and archives.

5. Medical Scribe Overview

EMR Workflow Support: Work under the direction of a provider to facilitate patient workflow within an electronic medical records (EMR) system, transcribing and entering information provided by the provider into the medical record.
Exam Room Transcription: Accompany the provider into the patient examination room to transcribe a history and physical exam.
Dictation Accuracy: Accurately document the provider’s dictation with the patient within the EMR system.
Clinical Detail Entry: Document all proper symptoms, diagnoses, follow-up instructions, and prescriptions as dictated by the provider.
Order Documentation: Document patient orders dictated by the provider, including required tests and medications.
Procedure Recording: Document any procedures performed by the provider.
Professional Collaboration: Maintain effective working relationships with providers and staff and demonstrate the H3W Leadership behaviors.

6. Medical Scribe Details and Accountabilities

Physician Support: Accompany the physician during patient interview and examination.
History Documentation: 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.
Exam Documentation: Document physical examination findings and procedures as performed by the physician.
Study Results Entry: Document the results of laboratory and radiographic studies as dictated by the physician.
Time Tracking: Document the correct time of patient care-related activities, including physician-to-physician communication, family communication, and re-examination of the patient.
Chart Review Process: Allow the physician to review all documentation completed by the scribe, make any necessary amendments, and sign the chart, as the physician is ultimately responsible for documentation of the patient’s encounter.
Chart Rounds: Make "chart rounds" with the physician to review patient status, delays, and any other care-related issues.
Order Communication: Ensure that all orders for patient care are communicated by the physician and not the scribe.
Care Boundaries: Refrain from participating in any patient care and refer all requests related to patient care to the responsible physician or nursing staff, including transporting specimens, answering phones, assisting patients, or calling physicians.
Team Collaboration: Maintain and demonstrate an understanding of the team approach to patient care and documentation.
Record Completion: Complete and present the medical record in collaboration with the supervising physician.
Ongoing Education: Participate in ongoing educational opportunities as offered by EMSOC/ScribeMD.
Meeting Attendance: Attend regularly scheduled EMSOC/ScribeMD staff meetings.
Professional Communication: Communicate professionally and respectfully with the supervising physician, ancillary hospital staff, and EMSOC/ScribeMD staff.
Confidentiality Compliance: Treat all information, data, and training materials utilized in the scope of the scribe position with complete confidentiality and security.

7. Medical Scribe Tasks

Provider Dictation: Perform provider documentation of patient information as dictated by a provider legibly and clearly, following all established local, state, and federal guidelines for documentation and billing.
Record Maintenance: Document and maintain patient care records completely and thoroughly.
Policy Compliance: Ensure that all documentation follows Scribe policies and procedures as outlined by MedExpress.
Record Requirements: Follow established medical record requirements.
Real-Time Completion: Complete all documentation in real time and within the same date of service.
Chart Communication: Communicate with the provider when the chart is complete and ready for review and sign-off.
Documentation Correction: Clarify and correct any documentation under the direction of the provider.

8. Medical Scribe Roles

Record Preparation: Prepare and assemble medical record documentation and charts for the physician before the patient visit in accordance with policy.
Visit Anticipation: Anticipate physician needs for patient visits by obtaining internal and external previous medical records and test results.
Documentation Accuracy: Ensure that all elements of documentation are complete and accurate.
Real-Time Transcription: Enter the patient room with the physician or clinician during a patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications.
Patient Communication Documentation: Document the physician or clinician's communication with the patient using appropriate medical terms and phrasing.
Order Preparation: Prepare (pend) orders, including follow-up testing, lab orders, medication orders, consults, and/or referrals, and connect the associated diagnosis with those orders.
Follow-Up Documentation: Document the correct follow-up instructions and level of service designation based on the physician or clinician's direction.
Data Entry Assistance: Assist in data entry from devices or other sources.
Record Completion: Complete medical records for each encounter, ensuring accurate and timely documentation.
Health Information Updating: Update patient history and other pertinent health information in the patient record under the physician or clinician.
Documentation Submission: Prepare and send all documentation for review and approval.
Clinical Support: Perform clinical functions with proven competency, such as preparing and rooming patients for exams, obtaining vital signs and documenting or updating pertinent health information, assisting the physician or clinician with non-sterile procedures, scheduling appointments and referrals, and performing additional data entry into the EHR.

9. Medical Scribe Additional Details

Clinician Support: Accompany clinicians into patient rooms and transcribe clinician dictations and notes.
Active Listening Documentation: Actively listen to all conversations pertaining to patient care between the clinician and other healthcare providers, patients, and family, and document relevant information into the EMR.
Encounter Documentation: Document clinician and patient encounters in the EMR.
Information Retrieval: Seek out missing information from clinicians to complete the physician's chart.
External Data Gathering: Gather and input pertinent patient information from external sources such as outpatient lab tests and nursing home or EMS records.
Communication Assistance: Place phone calls to PMD offices, pharmacies, and other parties as requested by the clinician.
Diagnostic Follow-Up: Keep clinicians informed of the resulting diagnostics and troubleshoot delays in those results.

10. Medical Scribe Duties

Exam Room Transcription: Accompany the physician into the patient examination area to transcribe a history and physical examination as given by the patient and physician or medical provider.
History Recording: Record details of chief complaint, history of present illness, review of systems, past medical history, social history, family medical history, disease risk factors, medications, and allergies into the medical record system.
Exam Findings Documentation: Record details of the physical exam, including pertinent positive and negative abnormalities and the patient’s general condition in the medical record system.
Procedure Recording: Record procedures and treatments performed by healthcare professionals, including nurses and support staff.
Lab Review Support: Review lab results with the medical provider and scan them to the patient's chart, including physician-dictated diagnoses, prescriptions, and instructions for patient or family members for self-care and follow-up.
Documentation Accuracy Review: Review medical documentation for accuracy or inconsistency by thoroughly checking the information to eliminate or reduce errors.
Clinical Data Entry: Ensure all clinical data, labs, or other test results, including the physician’s interpretation, are accurately recorded into the medical record.
Incomplete Record Notification: Notify the attending provider when a patient record is incomplete.
Consult Documentation: Document consults with other providers.
Compliance Standards: Comply with specific standards related to medical record style and the legal and ethical requirements for preparing medical documents and maintaining patient confidentiality.
Report Importing: Import radiology reports, lab results, and EKGs, and validate that test results are received and reviewed during the patient visit as directed by the medical provider.
Discharge Preparation: Prepare discharge summaries and follow-up instructions for patients.

11. Medical Scribe Details

Patient Observation: Observe and record patient encounters and examinations.
Clinical Documentation: Document patient information, history, and diagnoses.
Medical Management Support: Assist in medical management.
Decision-Making Documentation: Document medical decision-making.
Care Team Consultation: Consult with the care team and other providers on patient needs.
Provider Communication: Facilitate communication between providers and other staff.
Clerical Support: Perform other clerical tasks that optimize efficiency.

12. Medical Scribe Responsibilities

Exam Room Transcription: Accompany the physician into the patient exam room to transcribe history, physical exam, and procedures as stated by the physician during the interview and exam of the patient.
Record Authentication: Sign and date all entries in the medical record appropriately to identify role as Medical Scribe.
Result Tracking: Track the status and results of lab, x-ray, or other evaluations completed on the patient.
Provider Communication: Communicate with physicians and mid-level providers within the practice in a timely and efficient manner while exhibiting the Beaumont Health Standards.
Age-Specific Awareness: Understand physical, intellectual, psycho-social, and developmental tasks, major fears, and stressors significant for each age group served while providing a safe environment of care and recognizing safety risk considerations for each age group served.
Professional Conduct: Maintain standards regarding personal appearance, introduce yourself properly to the patient, and treat all patients with dignity and respect.
Front Office Support: Perform front office duties to provide coverage.

13. Medical Scribe Essential Functions

Medical Record Generation: Generate comprehensive medical records to optimize doctor time and enable robust, 24/7 care for members.
Clinical Experience Support: Gain valuable clinical experience working alongside world-class doctors in delivering patient-centered, comprehensive primary care services in a concierge-style model.
Supply Management: Assist with medical supply inventory and ordering.
Paperwork Assistance: Assist in clinical-related paperwork, including disability forms, referrals, etc.
Patient Communication: Assist with returning patient telephone calls.
Scheduling Coordination: Schedule imaging studies and injections.

14. Medical Scribe Role Purpose

EHR Documentation: Work alongside providers to document patient data into the electronic health records system during patient visits.
Data Accuracy: Ensure accuracy of patient information entered into the system.
Coding Compliance: Follow coding requirements during entry of patient information.
Data Retrieval: Retrieve data related to the patient visit.
Exam Room Preparation: Prepare, stock, and clean exam rooms with appropriate training.
Patient Rooming: Room patients, compile patient medical data, and prepare for x-rays.
Information Gathering: Assist with information gathering before and during the patient visit.
Surgical X-Ray Assistance: Assist in surgical X-ray procurement.
Cast Management: Apply and remove casts.
Prescription Processing: Obtain provider approval and call or fax prescriptions to the pharmacy.
Clinical Procedure Support: Prepare for injections, change dressings, apply durable medical equipment, and remove sutures or staples under provider direction.
Order Entry Delegation: Act as a prescribing delegate to enter medical orders such as medications, laboratory services, imaging studies, and other auxiliary services into the computerized provider order entry (CPOE) in the patient's electronic records under the direct supervision of the provider.

15. Medical Scribe General Responsibilities

Exact Documentation: Document or record the visit elements exactly as stated by the practitioner without interjecting personal observations or impressions.
Timely Recording: Capture accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter on time.
Record Navigation Support: Assist the practitioner in navigating the medical record.
Message Handling: Respond to various messages as directed by the practitioner.
Information Retrieval: Locate information for review, such as previous notes, reports, test results, and lab results.
Directed Entry: Document information into the medical record as directed by the practitioner.
EHR Entry: Enter information in the electronic health record, such as patient history, system review and physical examination, vital signs, procedures and treatments performed by the practitioner, care plan and medication lists, progress of lab, X-ray, or other patient evaluation data, and practitioner-dictated diagnoses, prescriptions, and instructions.
Information Research: Research information requested by the practitioner.
Authenticated Entries: Make entries in the electronic health record using your own password/access for all entries and clearly include the scribe’s name and a legible signature/electronic signature, the practitioner rendering services, the qualifications of each person, and authentication of the scribe, including accurate date and time of service.
Care Documentation Support: Support the practitioner in care documentation and data retrieval.

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