Medical Scribe / Medical Administrative Assistant

About the Role

We are looking for a detail-oriented and knowledgeable Medical Scribe to support healthcare providers with clinical documentation and administrative workflows during patient consultations.

In this role, you will work closely with physicians to document patient encounters in real time, prepare medical charts before appointments, assist with entering orders under physician instruction, and ensure clinical records are accurate, complete, and organized.

The ideal candidate has a strong understanding of medical terminology, excellent typing and listening skills, and experience working with electronic health records (EHRs). You should be comfortable working in a fast-paced clinical environment where accuracy, efficiency, confidentiality, and attention to detail are essential.

Requirements

Key Responsibilities

Real-Time Clinical Documentation

• 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.

Pre-Visit Chart Preparation

• 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.

Orders & Referral Entry

• 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.

Post-Visit Documentation & Chart Closure

• 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.

Coding, Compliance & Confidentiality

• 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.

Clinical Workflow Support

• 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.

Minimum Requirements

• 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.

Essential Skills & Competencies

• Clinical documentation: Ability to accurately capture patient information and physician instructions.
• Medical terminology: Familiarity with common clinical terms, diagnoses, medications, and procedures.
• Attention to detail: Ensures accurate documentation of medication dosages, clinical findings, and patient history.
• Active listening: Distinguishes important clinical information from general conversation.
• Time management: Completes documentation promptly while managing multiple tasks.
• Adaptability: Adjusts to different physician preferences, specialties, and documentation workflows.
• Confidentiality: Handles sensitive medical information professionally and securely.
• Communication: Works effectively with physicians and clinical teams to resolve documentation gaps.

What Success Looks Like

• Patient encounters are documented accurately and in real time.
• Clinical notes are complete, clear, and organized.
• Medical orders and referrals are entered correctly under physician instruction.
• Incomplete records are flagged promptly for provider review.
• Patient information remains confidential and is handled in accordance with applicable regulations.
• Documentation is completed efficiently, supporting smooth clinical operations and reducing administrative backlogs.

Important Note

The Medical Scribe supports the physician by documenting clinical information and carrying out authorized administrative tasks. Clinical decisions, diagnosis, treatment recommendations, and final approval or signature of clinical records remain the responsibility of the appropriately licensed healthcare provider.

If you have strong medical terminology knowledge, excellent attention to detail, and experience supporting clinical documentation, we encourage you to apply.

Originally posted on Himalayas