Medical Scribe

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Scribing 101: Fundamentals of Scribing

A medical scribe's role has become central to the healthcare industry. Medical scribes work alongside professional healthcare providers, shadowing them and documenting their encounters with their patients. 

A medical scribe will jot down a licensed healthcare's dictation story, consults, physical exam, imaging, and lab results, inputting these details in a facility's electronic medical record.

Updating Resume with Scribe Certification 

Since scribes serve to lessen a physician's patient records documentation burden, they do not have to be licensed medical practitioners. That said, medical scribes will transcribe a physician, physician assistant, or nurse practitioner’s dictation better if they have medical scribe training and certification.

Medical scribe certification gives you a paraprofessional status notifying would-be employers that you can help them save time and facility costs through efficient documenting. While it is true that a high school diploma qualifies you to work as a scribe, updating your resume with scribe certification shows potential employers that you have relevant experience, skills, and quantifiable achievements in this field. 

Getting Trained to Scribe in Common EMR Systems

You can attain medical scribe certification, after training and undergoing intensive on-the-job experience. Train as a medical scribe via online classes and physical training in large scribing institutions. There are also a wide variety of manuals and books that contain scribing education content.

As mentioned earlier, you only need a high school education to start your career as a medical scribe. Some medical facilities however prefer scribes that have a college education or higher education in specific courses such as pre-medicine or biology. 

Medical scribe training introduces learners to the wide range of responsibilities, demands, and roles in the medical field. Some of the topics that medical scribes receive training on for efficient EMR systems management include; 

●      Physiology

●      Anatomy

●      General medicine

●      Pharmacology

●      Lab, MRI, radiology, and EKG results

●      Discharge processes

●      Coding and billing

●      HIPAA, patient privacy, and medicolegal compliance

●      Workflow management and legal documentation

Medical Scribe Training Process

Medical scribe training process 

Online training

A new medical scribe will undergo a two-week classroom training period. They will learn medical terminology, common EMR systems software and documentation procedure, HIPAA compliance, coding, and billing. 

On-the-job training

In this phase, medical scribe students receive clinical experience working alongside professional health practitioners. They will work shifts under the supervision of trainers, receiving feedback and direction as they acquire real-life work experience. 

Certification

At the end of this supervision period, they will undergo an assessment in clinical scribing expertise and receive certification.

Continuous training

Trainees that plan to make scribing a long-term career should receive continuing education to keep them up-to-date and competitive in the job market. The best training institutions, therefore, work hand in hand with physicians and their facilities to offer more learning in specialized topics such as ER.

Applying to Scribe Jobs on Indeed

Most medical scribes train with large medical scribes’ businesses then get their work positions through them. Be that as it may, you can find a medical scribe independently by either applying to a medical facility or websites such as Indeed. 

Flexibility and professional qualifications such as proof of work experience and medical scribe certification will help you secure a well-paying position much faster. Indeed is an easy-to-use hiring platform that has a step-by-step job posting process that is very popular with the scribing community. 

It has over 250 million visitors each month. Job seekers have uploaded over 175 million resumes in Indeed's vast database. Indeed, provides detailed job applications guidance details that support easy job application procedures. 

Job applicants at Indeed love that they can filter locations, to view medical scribes’ jobs that are in their vicinity. Job postings on Indeed have details such as:

●      A full job description giving a general overview of the position. 

●      The position’s purpose

●      Your duties 

●      Working hours 

●      Job requirements 

●      The qualifications that you should hold to qualify for a particular job opening. 

To apply for a job opening that suits your details, Indeed postings have links that will direct you to a potential employer's job application page. To apply for a medical scribe job at Indeed, first, craft a robust resume. 

A well-done resume, medical scribe certification, and hands-on experience make you the perfect candidate for hiring experts. Below are some resume-building tips that will help you create an excellent resume for a job hunt at Indeed.

●      Be brief
Create a one-page resume

●      State the facts 
Avoid flowery expressions and cliches on your resume

●      Be accurate
Ensure that your name, address, work experience, and education details are accurate.

●      Be professional
Avoid distracting fancy fonts, backgrounds, designs, or emojis

●      Observe order
List your education and work experience in a reverse-chronological order 

●      Be relevant
Your resume's details should target the job listing's duties, skills, and objectives

Practice Medical Scribing in Various Application Scenarios.

Hospitals

Hospitals provide care, treatment, and diagnostic services to patients. Additionally, they provide intensive and emergency care. Most of these healthcare institutions have inpatient facilities and various disease care departments. 

Our medical scribe course teaches hospital scribes on inpatient workflow management, care for unique populations, appropriate and EMR documentation. In addition, hospital scribes will learn how to review patient history, prep, and lab charts and medication.

Outpatient Clinics

Outpatient clinics are short-term care facilities. They also have a lot of referral processes and non-emergency medical care. Outpatient clinic scribes create efficient workflows helping physicians see more patients each day. 

This efficiency improves patient outcomes and facility revenues. Along with this, an outpatient medical scribe's data recording prowess will support easy and effective referral systems.

Long-Term Care Facilities

Long-term care facilities support patients that have disabilities and ongoing health conditions. In addition, these facilities support patient completion of their daily activities in safety to enhance independence. 

Nursing center, hospice, and assisted living home scribes’ processes support primary care physician and specialist coordination. They submit all private insurer, Medicaid, and Medicare data on time to ensure that all patients receive care, prescription, and supplies on time.

Pharmacies & Telemedicine

Clinical labs are diagnostic centers. Diagnostic center medical scribe processes support the diagnosis, treatment, and monitoring of patient health.

Telehealth scribes or telescribes update EHR in real-time, enhancing efficiency. In addition, telescribes receive training on HIPAA-compliant document retrieval and chart preparation. 

Other Aspects of the Medical Scribe Course

Labs: There are many lab types in medicine. They include complete blood count, prothrombin time, basic and comprehensive metabolic panels. There is also the lipid panel, liver panel, thyroid-stimulating hormone tests, and hemoglobin A1C for diabetes conditions. Last but not least, there is urinalysis and cultures. Medical scribes will learn to identify abnormal lab tests but are not at liberty to report or diagnose the patients. 

The Clinical Impression: A clinical impression or assessment is a formulation of the patient's state by a trained health practitioner. The physician will dictate an initial impression after a full assessment. It is a concise paragraph noting the medical problems, mental status, resources, and support system that a patient has. 

Medical Coding: The medical coding scribe certification course will introduce you to diagnoses codes such as the ICD-10, CPT, and HCPCS Level II and their usage in different states. You will also learn to bill for medical claims and risk adjustment coding.

The Plan: This course will help medical scribes avoid any note-taking errors that may lead to erroneous or poor-quality prescribing. In addition, it will enhance their therapeutic objective, highlighting prowess and note-taking on drug therapy, warnings, instructions, and therapy evaluation.

Medico-Legal: Our Medico-Legal scribe certification course will help your clinic compliant to regulations by upholding the virtues of good and clear communication and top-notch record keeping. In addition, you will learn to take real consent, follow protocols, and how to keep abreast with the law.

Workflow: You will learn how to chart as per your health facilities preferences. Other important topics in this module include keeping in step with the physician's dictation, pre-charting, eliminating errors, and redundancies from notes for cohesiveness.