Patient documentation has always been a necessary part of delivering quality healthcare, taking up 33% of the total amount of time spent managing electronic health records (EHRs). Every patient encounter needs to be documented accurately because those records support continuity of care, reimbursement, and communication with other providers. However, as your patient volume grows, so does the amount of time your physicians spend documenting visits, leaving less time for patient care and other responsibilities that contribute to your practice’s long-term growth. As a matter of fact, the 2024 TrendBurden survey by the American Medical Informatics Association (AMIA) revealed that nearly 75% of its physician respondents believe that documentation does get in the way of patient care.
As a healthcare provider managing your own practice, finding ways to make documentation more efficient without compromising its quality is important, and one role that has gained significant traction in recent years is the virtual medical scribe position.
But how does a scribe help a physician with their workload, and what are the things that you should know about the role?
What Is a Virtual Medical Scribe?
Before discussing the medical scribe job description, it’s important to understand what makes virtual medical scribes different from traditional in-person scribes.
Like an in-person medical scribe, a virtual medical scribe helps physicians document patient encounters and maintain accurate medical records. The role is often filled by a medical virtual assistant from either freelancing sites like Upwork or dedicated VA companies like My Mountain Mover.
But unlike their in-person counterparts, virtual medical scribes work outside your practice, providing documentation support remotely through secure, HIPAA-compliant technology. They work alongside you and your team by documenting patient encounters, updating EHRs, and organizing clinical information while you focus on examining and treating your patients.
Although virtual medical scribes don’t provide direct patient care or make clinical decisions, they still play an important role in your practice’s daily operations. By taking documentation off physicians’ plates, they help reduce administrative burden without disrupting your existing workflow.
What Does a Scribe Do?
While every practice has its own workflow, the primary role of a medical scribe remains the same: reducing the amount of time physicians spend documenting patient encounters. However, their scribe duties are more than just typing down notes during appointments.
Depending on your specialty and documentation preferences, the duties of a medical scribe may include the following:
Documenting Patient Encounters
Clinical documentation is one of the primary medical scribe responsibilities. Throughout the entire duration of a visit, scribes note down critical information such as the patient’s medical history, lab results, and other observations you discuss with them directly into your preferred electronic health record system.
By keeping documentation updated in real time, medical scribes help reduce the amount of charting physicians need to complete after clinic hours. This not only improves documentation efficiency but also allows your providers to focus more on patient care during appointments.
Updating Electronic Health Records
Accuracy matters not only in creating an effective treatment plan but also in the continuity of a patient’s care. So, apart from documenting all the information discussed during patient visits, one of the common medical scribe responsibilities is keeping your EHRs accurate and organized.
Depending on your workflow, they may update patient histories, reconcile documentation, organize laboratory and imaging results, and make sure patient records remain complete throughout the course of treatment. Having well-maintained records also makes it easier for other providers involved in the patient’s care to review important clinical information whenever it’s needed.
Preparing Patient Charts
When you have patients who come back for a follow-up visit or simply trust the services you offer, having their charts prepared beforehand will not only shorten the waiting time but also help you brush up on their needs.
Medical scribes can review upcoming appointments, organize patient charts, and make sure previous visit notes, laboratory results, medications, and other relevant information are readily available before consultations begin. By helping physicians start each appointment with organized records, your practice can maintain a smoother workflow throughout the day.
Supporting Documentation After Visits
Documentation doesn’t always end when the patient leaves the exam room because more often than not, you will need your team to do regular check-ins with your patients to get updates on the changes in their condition.
Depending on your practice’s preferences, medical scribes may also assist with organizing pending documentation after appointments, updating records based on physician instructions, and preparing notes for final review and signature. This helps reduce documentation backlogs while keeping patient charts current.
Maintaining Documentation Accuracy
One of the most overlooked responsibilities of a medical scribe is maintaining consistency throughout your documentation.
Accurate records not only support continuity of care. They also help reduce documentation errors, strengthen communication among providers, and support billing processes that rely on complete clinical documentation. By paying close attention to detail, medical scribes help your practice maintain organized records that physicians can confidently rely on.
What Skills Should a Medical Scribe Have?
If you’re planning to hire a virtual medical scribe, understanding the medical scribe requirements goes beyond knowing what they do. You should also understand the medical scribe skills that allow them to perform the role effectively and contribute to your practice’s long-term success.
First and foremost, medical terminology is essential because much of a medical scribe’s work involves documenting highly specialized clinical information. Apart from that, they should also be proficient with your practice’s electronic health record system, as documentation quality depends heavily on how efficiently they can navigate your existing workflow.
Strong attention to detail is equally important. Since physicians rely on scribes to maintain accurate patient records, even minor documentation errors can create confusion later in the patient’s treatment journey. Your ideal medical scribe should also possess excellent listening, organizational, and written communication skills to accurately capture physician observations while keeping documentation clear and consistent.
Most importantly, medical scribes should understand the importance of patient confidentiality. Because they routinely access protected health information, they should be knowledgeable about HIPAA requirements and committed to handling sensitive patient information responsibly throughout every stage of the documentation process.
The Impact of Virtual Medical Scribes
Clinical documentation will always be an essential part of delivering quality healthcare. However, it shouldn’t compete with the time your physicians need to spend caring for patients.
By understanding what a virtual medical scribe does, the responsibilities they take on, and the skills they need to succeed, you’ll be in a better position to determine whether adding one to your team aligns with your practice’s goals.
Ultimately, virtual medical scribes don’t replace physicians. They help physicians make better use of their time.
Frequently Asked Questions
What’s the difference between a medical scribe and a medical transcriptionist?
Medical scribes document patient encounters in real time while physicians are seeing patients. Medical transcriptionists typically create documentation from recorded dictation after the encounter has already taken place.
Can one virtual medical scribe support multiple clinic locations?
Yes. Since they work remotely, virtual medical scribes can often support physicians across different clinic locations as long as the workflow allows for it.
Should every physician have their own dedicated virtual medical scribe?
Not necessarily. Some practices assign one dedicated scribe per physician, while others share documentation support based on scheduling and patient volume.
