Medical Scribe Resume Examples and Templates

Medical Scribe

• Designed and developed customized medical documentation templates specifically tailored for Head Physicians.
• Initiated and organized meetings with the EHR Program Customer Service Line to gain comprehensive knowledge of template creation, customization, and editing.
• Created personalized documentation templates for various Doctors and Physicians, aligning with their treatment protocols and meeting insurance audit requirements.
• Led multiple meetings with medical auditors, insurance companies, medical lawyers, and other healthcare businesses to understand the necessary components for doctor's reports to meet insurance approval standards.
• Incorporated this knowledge into customized templates to ensure they would pass insurance audits.
• Maintained awareness of schedule changes and had in-depth knowledge of treatments and reasons for each patient's visit.
• Demonstrated professional and efficient communication skills when preparing and debriefing with the Head Doctor.
• Delivered important information and knowledge clearly and concisely to individuals under treatment.
• Maintained composure and professionalism while multitasking in a high-traffic, fast-paced environment, performing job functions with attention to detail, speed, efficiency, and accuracy.

Medical Scribe

• Accurately documented physician-dictated patient history, present illness, past medical and surgical history, medications, and allergies.
• Demonstrated the ability to maintain confidentiality and privacy in compliance with HIPAA regulations.
• Maintained and exhibited an understanding of the team approach to patient care and documentation.

Medical Scribe

• Applied charges and kept patient records updated using eClinicalWorks.
• Conducted reviews of records, paperwork, and orders to identify errors and resolved issues independently.
• Documented comprehensive information pertaining to examinations, treatment plans, lab results, and other relevant details directly into patient charts.

Internal Medicine Medical Scribe

• Recorded patient visits in the Electronic Medical Record (EMR), compiled patient medical histories and specialist records, examined patient labs and records, facilitated referrals to external providers, prescribed medications and diagnostic studies, and assisted in conducting physical exams, pap smears, and diabetic foot exams.
• Contributed to the management of care for patients spanning various age groups, including children, adolescents, adults, and seniors.
• Accurately documented patient appointments for acute complaints, chronic care, and annual well visits.

Medical Scribe

• Meticulously records comprehensive patient exam details in the Emergency Room (ER) and triage departments, ensuring complete patient charts that encompass clinical history, current complaints, diagnoses, procedures performed, and dispositions provided.
• Demonstrates exceptional multitasking skills, efficiently completing charts while attentively listening for subtle environmental cues, promptly notifying doctors of patient results, and documenting every re-evaluation at each stage of the patient care process.
• Cultivates and sustains professional relationships with ER doctors and staff, maintaining a keen understanding of the ER floor's dynamics, adapting seamlessly during high-volume shifts, and prioritizing tasks that demand immediate attention.

Medical Scribe

• Collaborate with physicians to see patients and conduct real-time, comprehensive medical charting using the EMR (Electronic Medical Record) Scribe for multiple doctors and services, encompassing retina, glaucoma, diabetes, and cataracts.
• Assist in minor in-office procedures, such as chalazion/cyst removals, injections, and laser treatments.
• Proficiently administer accurate tests on patients, including intraocular pressure measurements, Fundus photos of the retina, and macula OCTs.

Medical Scribe

• Entered patient histories, physical examination findings, and medication details into either physical or electronic charts.
• Documented and initiated requests for tests, scans, and other necessary orders.
• Accurately identified appropriate ICD-10 and CPT codes for medical record utilization.
• Recorded physician-dictated diagnoses and completed prescription orders.
• Verified patient insurance information in compliance with HIPAA guidelines.

Medical Scribe Manager

• Entered patient histories, physical examination findings, and medication details into either physical or electronic charts.
• Documented and initiated requests for tests, scans, and other necessary orders.
• Accurately identified appropriate ICD-10 and CPT codes for medical record utilization.
• Recorded physician-dictated diagnoses and completed prescription orders.
• Verified patient insurance information in compliance with HIPAA guidelines.

Medical Scribe

• Recorded patient history, physical examinations, differential diagnoses, progress notes, consultations, and radiology results within the electronic health record system.
• Gained exposure to a diverse range of emergency cases, including trauma, stroke, orthopedic, respiratory, cardiac procedures, and minor surgical interventions.
• Effectively coordinated patient flow and throughput in the Emergency Department.

Senior Medical Scribe

• Successfully served as a Medical Scribe, handling multiple physician accounts specializing in Internal Medicine and Family Medicine in the United States.
• Proficiently utilized AthenaNet and CPHC electronic medical record systems.
• Competently added diagnoses and orders following ICD coding guidelines, and possessed comprehensive knowledge of CPT codes.
• Took on the role of a trainer, providing guidance to Medical Transcriptionists transitioning into the Scribe process.

Medical Scribe

• Enhanced physician efficiency in patient care through accurate and organized documentation in EPIC.
• Acquired comprehensive knowledge of medical terminology and honed clinical skills.
• Maintained well-organized patient charts while effectively managing multiple tasks in a high-intensity clinical environment.

Medical Scribe

• Evaluate abnormal lab results and update patients' records accordingly.
• Review patient histories and draft history and physicals, progress notes, and discharge summaries.
• Handle urgent tasks that require the physician's attention and relay an action plan.
• Provide follow-up care for in-office and hospitalized patients.
• Continuously monitor and follow up with patients enrolled in the Chronic Care Management plan.