Primary Responsibilities of a Medical Scribe
FREE PREVIEWPreparing for a Career as a Medical Scribe
Advanced Overview of SOAP Note
Guide to Obtaining Patient History
FREE PREVIEWExample H&P Admission Write-Up
Overview of Medical Terminology
Common Medical Abbreviations
Common Medical Terms
Medical Scribe Terminology Certification Exam
Part 1: Advanced Review of Anatomy & Physiology
Part 2: Advanced Review of Anatomy & Physiology
Part 3: Advanced Review of Anatomy & Physiology
Anatomy and Physiology Scribe Certification Exam
HIPPA and Patient Safety Review
HIPPA and Patient Safety Certification Exam
Interviewing and Patient Communication Case Practice
A very helpful course. My knowledge has improved significantly in the past few weeks. I highly recommend this course to everyone. Thank you Drs for bringing ...
Read MoreA very helpful course. My knowledge has improved significantly in the past few weeks. I highly recommend this course to everyone. Thank you Drs for bringing this course together.
Read LessThis course was really helpful. I took notes and will review them often to keep abreast with the cases. These will also help me communicate better with docto...
Read MoreThis course was really helpful. I took notes and will review them often to keep abreast with the cases. These will also help me communicate better with doctors. I truly enjoyed this course!
Read LessThe most advanced training that is correct. Recommend this to anyone who wants to be in prehealth!
The most advanced training that is correct. Recommend this to anyone who wants to be in prehealth!
Read LessThis is an accredited medical scribe program that is both affordable and goes in depth. I liked that they were transparent enough to have lots of demos. The ...
Read MoreThis is an accredited medical scribe program that is both affordable and goes in depth. I liked that they were transparent enough to have lots of demos. The flow made sense. They used lots of examples to help us think and review patient scenarios.
Read LessIt was a pleasure to take this course. I've learned that it is very important to practice writing cases, I have improved my ability to scribe, an now I can u...
Read MoreIt was a pleasure to take this course. I've learned that it is very important to practice writing cases, I have improved my ability to scribe, an now I can understand what it is I am writing.
Read LessIf you want to become a medical scribe, you need to be interested in medicine. You may need to complete medical scribe training which covers things like medical terms, the law, and how to keep information private. Once you finish the training, you can look for jobs by emailing clinics or applying online. If you're still in high school, you can enroll in a medical scribe certification to learn more about medicine.
A medical scribe is a person whose job it is to write down medical information. This is important because doctors and other medical staff need to be able to focus on the patient. With the added responsibilities of charting medical visits, ordering tests and treatments, reviewing medical history, and providing explanations to patients, the medical scribe takes on all of this documentation work. This allows staff to provide more individualized care to their patients. Medical scribes help by tracking patient information and creating reports for review by medical teams. They offer a range of services that make medical facilities operate more efficiently and effectively. As such, they play an essential role in modern healthcare.
A medical scribe assists physicians and other healthcare professionals in creating and maintaining accurate and comprehensive electronic medical records (EMRs) by documenting patient encounters, recording physician orders and providing administrative support during the patient visit. In addition to helping increase efficiency of patient care, a medical scribe may also help reduce physician documentation burden, provide real-time decision support, facilitate clinical workflow optimization, improve accuracy of data entry into EMRs and capture accurate billing information.
Medical scribes have the potential to make very lucrative salaries. On average, medical scribes can make about $18 per hour, roughly $3,100 per month, and up to $38,000 annually depending on their experience and locality. Additionally, certain states like California and Texas have higher pay rates for medical scribes. According to the Bureau of Labor Statistics, the median annual salary for medical scribes in 2018 was $34,750. This works out to an hourly rate of around $16.80 depending on local taxes and other factors. Furthermore, the top 10 percent of earners made more than $50,900 a year while the bottom 10 percent earned less than $22,450 annually in 2018.
A career as a medical scribe can be beneficial for those planning to attend Physician Assistant (PA) school, as it offers valuable experience in the healthcare field and provides insight into the job of a PA. Working as a medical scribe can give students first-hand exposure to administrative tasks related to patient care, such as gathering necessary information before office visits, documenting their physician's orders, and facilitating communication between members of the healthcare team. Additionally, scribes typically receive training on Electronic Medical Records (EMR) systems and other software platforms that are used in modern healthcare settings, which can come in handy when applying for PA school. By working as a medical scribe, students gain an understanding of the daily tasks that PAs are assigned and become better prepared to pursue their educational goals.
Working as a medical scribe offers the opportunity to gain valuable, hands-on clinical experience working in a hospital or physician's office environment. In this role, one is able to observe physicians and other healthcare professionals interact with their patients, learn about various diseases and treatments, and acquire an in-depth knowledge of the medical terminology and documentation practices used in a medical setting. Furthermore, one can hone their communication skills by taking dictation from physicians and accurately transcribing patient histories into electronic health records. These experiences create an invaluable foundation for those seeking to further their career goals in healthcare-related fields.
A high school enrollment may be acceptable for medical scribe training, however, in order to actually work as a medical scribe, a valid high school diploma or GED equivalent is typically required by employers.
Becoming a medical scribe offers a unique opportunity to gain valuable medical experience. As the demand for medical scribes continues to grow, so too does the need for certified medical scribes. Fortunately, there are many training options available that can equip you with the skills and knowledge necessary to pursue this rewarding career. Medical scribe training courses range from short introductory programs to comprehensive certification courses. These courses cover basic medical office procedures, medical terminology and record-keeping. Upon completion of medical scribe training and if preferred, you can obtain a medical scribe certificate or medical scribe certification from a recognized organization or medical institution. Certified medical scribes are in high demand in hospitals and medical offices across the country, and undertaking the necessary training and certification requirements will increase your employability and marketability as a medical professional. With hard work and dedication, you can become an invaluable asset in any healthcare team! So if you are looking to hone your skillset or advance your career as a medical professional, consider becoming a certified medical scribe today. You may never realize just how impactful your efforts can be! Invest in yourself by gaining valuable certifications that will set you apart -- become a certified medical scribe today! Your future self will thank you.
I am an experienced and certified Entry-Level Medical Scribe with a passion for providing excellent patient care, efficient data entry skills and a commitment to accuracy. I have extensive experience in recording and transcribing medical records using Electronic Health Record (EHR) systems, as well as organizing, managing and accurately entering clinical documentation into the appropriate databases. Additionally, I have gained a range of medical knowledge through my certification courses, which has allowed me to become an expert in medical terminology, anatomy and physiology, pharmacology, laboratory values and common diseases. My ability to communicate effectively with healthcare providers is a key strength that enables me to capture accurate information while ensuring exceptional patient care.
Certified medical scribes are in high demand, with job opportunities for medical scribe positions opening up in medical offices, medical clinics, and medical transcription services across the nation. As a medical scribe, you'll be responsible for accurately recording medical information as dictated by a medical practitioner or supervisor. You will also be expected to document patient visits and record medical charts as directed. Your work as a medical scribe will help determine diagnoses and treatments while increasing quality of care and efficiency of patient visits. The skills learned while working as a certified medical scribe can open up other related career options such as health records clerk, medical office specialist, coder, transcriptionist, and more. With an average annual salary of over $30K per year plus valuable experience at many healthcare facilities, there’s no limit to where a career in medical scribing could take you! So if you're looking for an exciting career path with the chance to make an impact on the healthcare industry, then applying your certification toward medical scribe jobs is definitely worth
1. What led you to pursue a career as a medical scribe?
2. How proficient are you at using various computer applications such as Microsoft Office Suite, including Word, Excel, PowerPoint and Outlook?
3. Describe your familiarity with common medical terminology, abbreviations, and documentation protocols.
4. What type of feedback have other healthcare professionals expressed regarding your performance while working as a medical scribe?
5. Are you familiar with Electronic Health Record (EHR) systems such as Epic, Cerner and Athenahealth?
6. What strategies would you use when challenged with complex professional interactions while scribing for a physician during a patient visit?
7. Do you have experience entering orders into medication administration software such as CPOE or eMAR systems?
8. What qualifications do you possess that make you an ideal candidate for this position as a medical scribe?
9. Describe your ability to work under pressure while accurately capturing patient data in real time during medical visits.
10. Explain how your attention to detail and quick problem-solving skills can assist physicians in delivering quality care efficiently and effectively.
11. Are you willing to travel between different clinical sites if needed?
12. What experience do you have in medical record-keeping and charting?
13. Describe your capacity for multitasking in order to ensure timely completion of multiple tasks within deadlines without compromising accuracy or quality of work product.
14. Are you comfortable working independently or collaboratively with team members when needed?
15. Are there any particular areas of physical exam documentation that you specialize in or feel confident about performing?
16. Do you have any prior experience transcribing physician dictation or lengthy patient histories?
17. Explain what makes communication between yourself and physicians during patient visits especially important for successful outcomes of the visit's purpose/goals/objectives.?
18. How do you stay up to date on the latest trends in healthcare technology and clinical documentation?
19 .Do understand the importance of maintaining confidentiality when it comes to the handling of protected health information (PHI)?
20 .How might your previous administrative experience help shape your performance as a medical scribe moving forward into this role ?
Becoming a medical scribe is a great way to gain medical experience and set yourself apart from the pre-med crowd. A medical scribe works closely with physicians in medical settings, documenting patient visits and gathering medical information.
Certified medical scribes are in high demand, with job opportunities for medical scribe positions opening up in medical offices, medical clinics, and medical transcription services across the nation.
If you’re looking for an exciting and rewarding career in the medical field, becoming a certified medical scribe may be the perfect choice for you. Medical scribes are essential members of any healthcare team and play a vital role in ensuring that patients receive quality care. With our advanced medical scribe certification program, you’ll have everything you need to start your career as a medical scribe. So what are you waiting for? Enroll today!
1. Responsibilities of a Medical Scribe :The responsibilities of a medical scribe include recording information from consultations with patients and other practitioners, as well as verifying that all interactions recorded in an EHR/EMR system have been observed. In this module, you will learn what it takes to get started in your career as a health records assistant, including being able to verify every detail during conversations between practitioners and clients or patients.
2. Medical Scribe Note-taking: Module 2 will cover everything that goes into a medical note, like what your symptoms are and how you're feeling. You'll learn how to write in traditional SOAP format, which stands for subjective assessment & objective findings. That means only including the important details and leaving out anything extra.
3. Medical Terminology Certification: This chapter provides you with an opportunity to learn the terminology used in science, technology, and medicine. The unit includes a range of terms, from simple symptoms to advanced test terms and names for complex conditions. There are also standard abbreviations.
4. Scribe Anatomy & Physiology: In this module, you will learn about the human body and how it functions. The content covers structural organization at tissue levels as well as functional specialties within organs such as hearts or lungs!
5. HIPPA and Patient Safety for Scribes: In this unit, we will be talking about how to keep your patients safe. We will be discussing key concepts in the Health Information Portability Accountability Act (HIPPA) and what constitutes sensitive information or PHI. We will also be discussing how to ensure compliance while handling things like diagnose descriptions and test results.
6. Scribe Interviewing and Communication: Module 6 is about why it is important to communicate well when you are talking to patients and working with other doctors. It talks about how to listen carefully, ask questions when you need more information, and make sure everyone understands what was said before moving on.
7. Scribe Medical Cases: This chapter provides an overview of some of the most common health complaints, including abdominal pain, constipation, diarrhea, injuries related to falls and strains, insect and animal bites, diabetic and hypertensive complaints, allergies and rashes, common cold cough, fever eye and ear infections, women’s reproductive health issues, as well as antenatal care.
8. Scribe History of Present Illness: This chapter explains why it is important to write a clear and detailed History of Present Illness (HPI). This includes describing the patient's symptoms, how often they occur, how long they last, and what makes them better or worse.
9. Scribing Other Past History: This unit will teach you about the things in a patient's life that usually help doctors understand what is wrong with them and how well they will respond to treatment. This includes things like their past medical history (like health conditions, allergies, and medications), their family medical history, and their current habits (like alcohol and drug use).
10. Scribing Review of Systems: The chapter talks about an important part of the first meeting with a doctor, when the doctor asks the patient lots of questions about their overall health. This is called a Review of Systems (RoS). The doctor also assesses the patient's mental condition through a Mini Mental Status Exam (MMSE). This information can help the doctor accurately diagnose a medical problem.
11. Scribing Vital Signs: In this unit, we cover how to take a patient's vital signs during the initial consultation. Vital signs include body temperature, heart rate, blood pressure, and respiration rate. It is important for scribes to be able to accurately record these measurements in the chart.
12. Scribing Physical Exam: This chapter provides an in-depth guide for how to document the results of your detailed physical exam. It includes everything from head tilts and coughs, ear inspection (including outer/middle ages), throat gagging maneuvers when necessary--all with a view towards determining each patient's overall health status.
13. Scribing Labs and Imaging: In this unit, we will cover the most common laboratory tests and imaging procedures recommended for patients. These tests include blood work-ups, such as a complete blood count (CBC), basic or comprehensive metabolic panel (BMP/ CMP), hemoglobin A1C, lipid panel, thyroid stimulating hormone (TSH), prothrombin time (ProT) and urinalysis (analysis of urine). We will also cover sputum, urine, stool and genital cultures. Common imaging techniques include Xrays, mammograms, computerized axial tomography (CAT/CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, ultrasound and fluoroscopy.
14. Medical Scribe Assessment and Plan: The next section will teach you how to make an A/P. This is a record of information that needs to be included in order for it be useful, and there are certain standards by which all such documents must meet! Ex: The patient is a [age] year old [male/ female]. They are experiencing [symptoms]. Their current medical problems are [problem] with test results of [test results]. They also have a chronic condition of [chronic condition], which has baseline function indices of [baseline function indices]. The likely diagnosis is [likely diagnosis], and the precipitating factor is most likely[precipitating factor]. The exacerbating factors are things that could potentially worsen the patient's condition, and they are as follows: [exacerbating factors]. The recommended medications for this patient are as follows: [recommended medications], and they should also make the following dietary changes: [dietary changes] Finally, they should also make the following lifestyle changes: [self-care, precautions].
15. Urgent Care Scribe Training: There are many different types of medical conditions that can show up at an urgent care clinic. Some patients come with life-threatening problems, while others may only need some over-the counter medication for their symptoms to go away in the meantime - but it's important not get too caught up on what type someone presents as soon as they enter your doors! This unit provides guidelines about assessing risk when seeing new clients so you know how urgently each problem needs attention without making assumptions based off outdated knowledge or bias from previous experiences alone
16. Emergency Medicine Scribe Training: The Emergency Department is a chaotic and confusing place. There are so many complaints, each with their own set of protocols to follow! This chapter provides an overview for ED staff members who may not be familiarized in detail on how they should handle different types cases seen there - from acute dehydration or electrolyte imbalance all the way down through hypo-glycemia & hyperglycemia vasodilatory shock/sepsis botulism trauma accidents etc. For every type outlined above (and more), we cover what you'll typically encounter during consultations along side ‘work ups’ which include assessments labs tests scans procedures advice medications dietary care techniques
17. Family Medicine Scribe Training: The goal of this chapter is to help you become a better listener and documentation expert. Learn how identify frequently encountered patient RFVs (reason for visit), like muscle pain or high blood sugar levels, in order document them properly so they can be seen more quickly by doctors who know what's going on with their patients!
18. Cardiology Scribe Training: The Cardiovascular Chapter is a comprehensive guide to the most common heart related conditions. It includes information on how you can diagnose and treat these issues, as well what assessments are necessary for diagnosis or care recommendations - including an explanation of commonly used terms that might be new outsider medicine readers come across while reading through this text!
19. Endocrinology Scribe Training: Hypothyroidism, growth hormone deficiency and Androgen imbalance are all covered in this chapter. There's also a brief discussion on endocrine problems like Cushing’s syndrome or Paget’s disease as well as their treatments.
20. Pulmonology Scribe Training: The causes of common pulmonary symptoms are discussed in this chapter. Important concepts covered include how to interpret the FEV1/FVC ratio, lung pressure curves and ABGs (arterial blood gases). By end, trainees will be able differentiate between conditions such as asthma or COPD with emphysema because they now know what each diagnosis entails on an airflow level.
21. Gastroenterology Scribe Training In this unit, we will take a close look at how digestion works normally, and what goes wrong in abnormal digestion. We will study diseases caused by problems with the structure of digestive organs, and diseases caused by problems with how they work. These include conditions such as GERD (gastroesophagal reflux disease), peptic ulcer disease, inflammatory bowel disease and cancers affecting various parts of the digestive tract. We will also learn about different ways to treat these conditions using drugs and surgery.
22. Neurology Scribe Training: This unit will go over the most common CCs that are seen in neurology department. This includes things like vertigo, seizures, and migraines. We will also cover topics like the nervous system, different types of illnesses, and how they impact the brain.
23. Nephrology Scribe Training: This chapter covers the different types of diseases and conditions that are treated by nephrologists. It also gives an overview of the causes, symptoms and treatment options for each condition. Some of the conditions discussed include glomerulonephritis, nephritis and necrosis, Berger’s disease, Alport syndrome, adult polycystic kidney disease, nephrolithiasis (kidney stones) and urinary tract obstruction. The chapter also covers dialysis protocols for different conditions as well as patient needs, including hemodialysis and peritoneal dialysis.
24. Hematology and Oncology Scribe Training: In this unit, trainee scribes learn about how blood is formed, what it is made of, how it flows and how it is used by the body. They also learn about diseases that can happen when something goes wrong with any part of the blood system. These diseases include anemias and thalassemias, thrombotic conditions, bleeding disorders, myeloproliferative disorders, lymphatic system disorders and cancers of the blood and bone marrow. The trainee scribes also learn about different drugs that are used to treat these conditions, as well as how to safely transfuse blood between people.
25. Rheumatology Scribe Training: This unit provides an overview of autoimmune disorders, such as hemolytic anemia, MG or myasthenia gravis (with particular coverage of thyroid sub-type Graves disease), rheumatoid arthritis, Sjogren’s syndrome, juvenile idiopathic arthritis, lupus erythematous, scleroderma, ankylosing spondylitis. It also covers the pharmacology of immunosuppressive medications such as TNF-α and IL antagonists (suppressants of Tumor Necrosis Factor alpha and Interleukin), glucocorticoids, DNA-alkylating agents. The unit also differentiates between conditions with and without autoimmune etiologies (e.g., gout versus rheumatoid arthritis), as well as among different autoimmune conditions.
26. Ophthalmology Scribe Training: The unit goes over common problems with people's eyes, including floaters and flashing lights, blurry vision, itching and tearing, red and painful eyes, and headaches. The unit also teaches how to do a vision test, including checking for visual acuity, pupil dilation, and ocular pressure. Additionally, the unit covers the anatomy of the eye and surrounding muscles, as well as major pathologies such as glaucoma, diabetic retinopathy, retinal detachment, AMD or age-related macular degeneration.
27. Surgical Scribe Training: The chapter covers the protocols for various kinds of surgery in detail. This includes both procedural and anatomical requirements. The content covers the gastrointestinal, heart, lung, ENT, genitourinary and neurosurgery fields. Within each field, the protocol covers important precautions, pharmacological support as well as surgical procedures. Additionally, the unit addresses surgical reduction and/or removal of cancerous tissue. A separate section covers protocols and precautions in pediatric surgery.
28. Orthopedic Scribe Training: This chapter gives an overview of conditions that need orthopedic treatment. This includes reviewing important considerations before beginning treatment, such as HTN (hypertension), diabetes, and coronary disease history. Conditions covered include fractures and dislocations, thrombotic conditions like DVT (deep venous thrombosis) and PE (pulmonary embolism), musculoskeletal traumas, and neurological conditions such as cauda equina syndrome. Orthopedic treatment approaches covered in detail include splinting, casts, traction, and surgical correction. Other processes that are covered include injection, aspiration, electrocautery, and tourniqueting.
29. Plastic Surgery Scribe Training: In this chapter, you will find out all about plastic surgery and its protocols. Topics covered include how to heal a wound properly so it doesn't recur as well as other aspects such us reconstructive surgeries for defects like chest wall reconstruction after being hurt in an accident or following disease where there was once skin loss due too cancer treatment but now has been restored using different types of tissue expanders that help restore what was lost while also giving back hope!
30. Psychiatry Scribe Training: This unit will cover a lot of different types of mental disorders, like anxiety disorders, mood disorders, eating disorders, substance abuse problems, personality disorders, and more. We'll also talk about some of the ways that these conditions can be treated, like with different types of therapy or medication. And finally, we'll go over some of the different ways that these disorders are classified.
30. Psychiatry Scribe Training: This unit will cover a lot of different types of mental disorders, like anxiety disorders, mood disorders, eating disorders, substance abuse problems, personality disorders, and more. We'll also talk about some of the ways that these conditions can be treated, like with different types of therapy or medication. And finally, we'll go over some of the different ways that these disorders are classified.
31. Ophthalmology Scribe Training: This unit provides a detailed overview of the basics of identifying conditions that present to the dermatology department. The content includes a primer on the structure of the skin and different types of skin cells, as well as different types of skin disturbances (e.g., nodules, pustules, papules, lesions, scabs). The chapter also covers various pathological processes (e.g., spongiotic, psoriasiform, vesicobullous, granulomatous) in depth. Finally, the unit provides an introduction to major types of skin cancers (e.g., basal cell and squamous carcinomas, melanomas).
32. Radiology Scribe Training: This unit covers important aspects of documentation for radiological procedures, including the following: The purpose of a scan. For example breast imaging (screening vs diagnostic). The type(s) and number views; multiple scans performed to obtain complete picture inside condition such as chest X-ray or craniotomy with CT scanning technology. Contrast agents used in MRI exams like SPECT.
33. Epic Scribe Training: Trainee scribes are given a comprehensive tutorial on how to navigate through the EPIC EHR system, including an overview of the EPIC interface and important aspects of case documentation. Tips are provided on building efficient workflow using EPIC, with tips on running Quick Chart Search on inpatients, use of SmartPhrases in note taking, setting up note templates for commonly seen medical problems, as well as a separate section on documenting outpatient or Ambulatory cases.
34. EMR Scribe Training: The unit provides an in-depth walk-through of documenting medical records using different EMR system. The detailed tutorial includes crucial aspects of medical documentation, such as: creating patient IDs and managing provider schedules; building a case record; creating orders, prescriptions and bills; documenting case details within PowerChart; and billing CPT modifier codes. Additionally, the chapter includes tips and tools on improving documentation speed and workflow efficiency.
A medical scribe helps doctors by writing down what the patient says, the patient's symptoms, and what codes, medications, procedures, and treatments the doctor plans to use.
The medical scribe job description includes recording medical history, orders, testing results, medical decisions, diagnoses, and treatments in medical documents.
Medical scribes help with medical charting, transcription, and documenting medical history and orders. The average salary for a medical scribe is $20 per hour. ScribeAmerica provides good job opportunities for pre-med students.
One way to become a medical scribe is to complete medical scribe training or an approved course in medical transcription. Once trained, medical scribes earn salaries up to $50k that are comparable to medical assistants.
Becoming a medical scribe is a great way to gain medical experience and set yourself apart from the pre-med crowd. A medical scribe works closely with physicians in medical settings, documenting patient visits and gathering medical information. They also handle data entry, administrative tasks, filing paperwork, and other assorted tasks. Medical scribes are an invaluable resource for medical professionals, increasing efficiency and helping them free up time to focus on their patients. Becoming a medical scribe requires some upfront work: you'll need to undergo training to learn medical terminology, creative writing skills, and other vital abilities. But once that's done, you've heftily increased your chances of success as a premed applicant or medical student. The ability to demonstrate hands-on medical expertise can open many doors for you in the medical community. Whether you're looking for part-time or full-time premed jobs or simply want real medical experience to pad your medical school applications, becoming a medical scribe is one of the best options available. Investing the time upfront can pay off big dividends down the line.
Medical scribes are a valuable asset to medical practices, providing support for medical staff and allowing them more opportunities for patient care. As a medical scribe, you'll be responsible for accurately entering medical data into medical records, prioritizing patient information, and quickly communicating between medical staff and patients.
