Medical Scribe - Chart Preparation (Non-Voice)
Internshala
About the job
About Excel Scribe
At Excel Scribe, our goal is to help physicians focus on patient care with minimal technological intrusion and restore the human touch in patient-physician interactions. We aim to reduce administrative burden, alleviate physician burnout, and improve patient outcomes through high-quality clinical documentation support.
About the Role
We are seeking Medical Scribes with a Bachelor of Dental Surgery (BDS), Bachelor of Pharmacy (B.Pharm), or MBBS degree and a strong understanding of medicine and clinical documentation. The Medical Scribe will work closely with an Internal Medicine physician and prepare patient charts within the EHR. This is a non-voice chart preparation role. The scribe will review, extract, organize, and summarize clinical information from one EHR and prepare complete documentation within another EHR based on physician instructions and established workflows.
Responsibilities
- Prepare and update patient charts in the EHR
- Review and document:
- History of Present Illness (HPI)
- Past Medical History
- Family History
- Social History
- Review of Systems
- Physical Examination
- Vitals
- Laboratory Results
- Assessment and Plan
- ICD Codes
- Ensure Assessment & Plan, Medications, and ICD Codes are accurately aligned and free of omissions or inconsistencies
- Perform medical review and medical summarization of patient records
- Maintain high standards of accuracy, quality, and turnaround time
Requirements
- Bachelor of Dental Surgery (BDS), Bachelor of Pharmacy (B.Pharm), or MBBS degree (mandatory)
- Minimum 2 years of experience as a virtual medical scribe in US Healthcare
- 3+ years of experience preferred
- Strong understanding of human anatomy, disease processes, and medications
- Experience with medical review and medical summarization is preferred
- Excellent typing and computer skills
- Strong attention to detail
- Ability to learn quickly and work independently
- Professional, reliable, and accountable work ethic
- Excellent written and spoken English communication skills
- Familiarity with PointClickCare (PCC) and other EHR systems is preferred
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