There was a time when a physician met with their patient, examined them and jotted down some quick notes. They handed the patient a prescription if needed, set the patient’s file on the desk and a secretary refiled it. With recent and continuous changes in rules and regulations, billing requirements, electronic medical records, and quality assurance requirements, those little notes have become a burdensome amount of documentation. So much relies upon the contents of the medical record that it has, in many instances, become the center of the provider’s attention.
Enter the medical scribe! The role of a medical scribe differs from a medical transcriptionist in a vital way. A medical transcriptionist converts voice-recorded reports dictated by physicians or other healthcare professionals into text format, which is later added into the patient’s medical chart. The medical scribe, however, is present with the physician or other healthcare provider while they are seeing the patient. Their job is to remove the burden of documentation from the provider so they can focus their time and energy on treating the patient. Afterwards, the scribe completes the documentation to meet both the physician's expectations and facility health information management protocols or standards. In addition to completing medical records, the scribe also collects and organizes the data required to meet various legal and ethical requirements of the facility related to quality assurance and data reporting.
The standard knowledge that is required to be successful as a medical scribe includes basic anatomy and physiology, an understanding of HIPAA (Health Insurance Portability and Accountability Act) rules and regulations, an understanding of medical billing, and knowledge of electronic medical record systems. There are a number of areas in which a medical scribe can become skilled. These include internal medicine, emergency departments, cardiology or any other area in medicine where a provider desires to remove themselves from the physical data entry required by his/her practice.
This course is offered in in-person group format and online. All our instructors are experienced medical providers.
Our course may be used for required job training. There are two components to our training. The first is the Medical scribe certification course. The second is our clinical documentation EHR course. You will receive two continuing medical education credits from the American Medical Association, the American Nurses Credentialing Center, and the Accreditation Council for Pharmacy Education after you have taken both components and filled out the course evaluation form.
See our accreditation letter.
Our medical scribe certification course front matter and our clinical documentation EHR course front matter include the course syllabi, complete accreditation statements and statements from all instructors and contributors.
This course is written based on scientific evidence. Our main works cited for this course are:
Additional information is available for organizations that are reviewing our course, just ask us.
Please verify the authenticity of our certificates by emailing us with the name and issue date of the student.