Scribe

Medical Scribe

Location: Raleigh, NC Schedule: Monday – Thursday, 8:00 AM – 5:30 PM

Position Summary

The Scribe will document information in the electronic medical record at the direction of the physician or advanced practice clinician. The Scribe will document the provider's dictation and/or activities. Any individual serving as a Scribe will have no patient care responsibilities or offer clinical oversight. An individual serving as an in-person Scribe may also serve as a chaperone during sensitive exams after completion of required education.

• Knowledge of medical terminology strongly preferred.
• Completion of medical school coursework or prior medical scribe experience strongly preferred.

• Accompany Physician into patient exam rooms and document patient encounters in real time.
• Accurately record patient histories, physical examinations, assessments, treatment plans, and provider recommendations in the EMR.
• Document laboratory results, diagnostic testing, procedures, and follow-up instructions as directed by the provider.
• Ensure medical records are complete, accurate, and compliant with organizational standards.
• Assist with chart preparation prior to patient appointments.
• Update patient records and maintain confidentiality in accordance with HIPAA guidelines.
• Communicate effectively with the provider and clinical staff to support efficient patient flow.
• Review documentation for completeness and accuracy before finalization.

• Education : High School Diploma or GED, required. 4 Year / Bachelors Degree, preferred.
• Experience : Six months customer service environment experience in the medical field, preferred.
• Additional Skills (required): Working knowledge of medical terminology and technical spelling. Computer aptitude and ability to quickly learn new applications. Communication and organizational skills with focus on tracking patient care and improving patient flow. Ability to record information accurately and promptly. Aptitude to learn or have knowledge of exam, diagnostic and treatment procedures and protocols. Professional demeanor and recognition of privacy considerations for patients and families. Completion of the computer-based learning entitled AMB0742 NHMG Chaperone in the Exam Room if the Scribe will also be serving as a chaperone during sensitive exams.
• Additional Skills (preferred): Specific medical terminology training, knowledge of basic anatomy, coding and HIPAA familiarity, medical, procedural and diagnosis coding experience.

At Novant Health, we believe remarkable care starts with compassion for our patients, our communities, and each other. We value belonging, courage, personal growth, and teamwork, creating a space where everyone is respected, supported, and safe to show up as their full selves.