Medical Scribe

Tufts Medicine - Boston, MA

Full-time - Entry Level

Boston, MA

Ambulatory Health Care Services

About the position

The Medical Scribe role at Tufts Medicine focuses on providing administrative support to physicians by documenting patient encounters in real-time. This position aims to enhance the efficiency of patient care by allowing physicians to concentrate on clinical responsibilities while ensuring accurate documentation of patient histories, examinations, and other relevant information. The scribe works closely with a physician, assisting with clerical tasks and navigating electronic medical records (EMR).

Responsibilities

• Assigned to work with one physician at a time.
• Accompanies the physician in the exam room for the patient interview and examination.
• Documents the physician's dictated patient history, history of present illness, review of systems, past medical and surgical history, family and social history and allergies and medications.
• Documents the physical examination findings as dictated by the physician and any procedures performed.
• Lists diagnoses and symptoms as directed by the physician.
• Documents lab and radiology results as instructed by the physician.
• May document time spent on patient care related activities, MD to MD communication and patient re-examination, if applicable.
• May be present and record the physician's consultations with family members or other physicians about a specific patient's case.
• Documents any procedures performed by the provider including nurses.
• May gather data about the patient prior to and following the visit including medical records from referring MDs, lab, radiology results and other data for review.
• Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group's achievement of goals, and to help foster a positive work environment.

Requirements

• Enrolled in undergraduate university studies.
• One (1) year of experience in a medical setting.

Nice-to-haves

• Enrolled in undergraduate university study studying biology or pre-med.
• Two (2) years of experience in a medical setting.