Medical Scribe / Medical Administrative Assistant

• Accompany physicians during patient consultations and examinations to document clinical encounters in real time
• Record the patient's chief complaint, history of present illness, relevant medical history, physical examination findings, and assessment and treatment plan
• Accurately capture clinical information while listening to conversations between healthcare providers and patients
• Adapt to different physicians' documentation preferences and workflows
• Review patient medical records before consultations
• Check medication lists, previous clinical notes, pending laboratory results, and imaging reports
• Ensure relevant information is available to the physician before the appointment
• Identify missing information or outstanding results that may require follow-up
• Enter laboratory, diagnostic imaging, and other medical orders under the direct instruction of the physician and in accordance with approved procedures
• Assist with entering referrals and prescription information as authorized
• Ensure all entries are accurate and flag discrepancies or missing information for the provider's review
• Review and organize clinical notes following patient consultations
• Assist with visit summaries and supporting documentation
• Identify incomplete sections and flag records requiring physician review, correction, or signature
• Help ensure patient charts are completed accurately and within the required timeframes
• Ensure documentation captures the clinical details required to support accurate medical coding and billing
• Follow applicable patient privacy, confidentiality, and healthcare documentation requirements
• Maintain the accuracy and integrity of electronic medical records
• Handle sensitive patient information responsibly and in accordance with applicable privacy regulations, including HIPAA where relevant
• Assist with patient flow by keeping documentation up to date and helping reduce administrative backlogs
• Manage multiple documentation tasks and outstanding items efficiently
• Communicate with physicians and relevant clinical staff regarding incomplete records or documentation discrepancies
• Maintain organized records and follow established clinical workflows

• Previous experience as a Medical Scribe or in a closely related clinical documentation role is preferred
• Strong knowledge of medical terminology, anatomy, physiology, common diagnoses, and clinical abbreviations
• Experience using electronic health record (EHR) systems such as Epic, Cerner, Allscripts, or similar platforms
• Excellent typing speed and accuracy; a typing speed of 60–80 words per minute is preferred
• Strong written English skills and the ability to produce clear, accurate clinical documentation
• Excellent listening skills and the ability to capture relevant clinical details during live consultations
• Strong attention to detail and the ability to identify missing or inconsistent information
• Understanding of patient confidentiality and healthcare privacy requirements
• Ability to work efficiently in a fast-paced healthcare environment
• Ability to accurately capture patient information and physician instructions
• Familiarity with common clinical terms, diagnoses, medications, and procedures
• Ability to distinguish important clinical information from general conversation
• Ability to complete documentation promptly while managing multiple tasks
• Ability to adjust to different physician preferences, specialties, and documentation workflows
• Ability to handle sensitive medical information professionally and securely
• Ability to work effectively with physicians and clinical teams to resolve documentation gaps