Careers
Explore the wide opportunities in the field of Medical scribing.
Today Medical Scribes are in great demand. So, if you are passionate about pursuing a scribing career, you will have innumerable opportunities in the healthcare system. While many see medical scribing as a steppingstone to their future career, you will also gain valuable skills and experience that you can utilize in any career.
We offer quality job-oriented training course in Medical scribing which enhances employability skill sets of students. Students who have acquired basic skills with CPMC training programs are employable/trainable in the vast and varied industry of Medical Scribing (also known as Medical Documentation), like:
• Electronic Health record officers are responsible for managing patient health records.
• They review each patient's physical chart, including the medical history, doctor's notes, current medications and enter that information into an electronic database system.
• They provide efficient health records service to patients, medical and nursing staff. They organize, update and store records and also send these electronic patient records to other departments for billing or insurance etc.
• Another key job responsibility includes running reports like reports on procedures, such as checking who is accessing information, how long records are being reviewed and from which terminals etc. Other reports such as comparing the medical records of each patient with each office visit to check for consistency etc.
• Medical records managers are responsible for maintaining and securing all written and electronic medical records within a facility's medical records department or its equivalent and may also supervise employees within the department.
• They are responsible for accuracy completeness, confidentiality & security of all healthcare information.
• Medical records managers also collect data for medical research and for calculating hospital occupancy rates.
• Virtual scribes listen to live conversation between Physician-Patient interaction via video conferencing or phone from an offsite location.
• Interpret and document key clinical information and generate comprehensive medical records in the customer provided template.
• Document medical visits and procedures as they are being performed by the physician.
• Prepare referral letters as directed by the physician, via dictation or summary of the medical record.
• Research contact information for referring physicians, coordinate referrals, prepare operative reports, and other tasks as assigned.
• Monitor the incoming audio files, rework rejected documentation by providers.
• Notify client on issues that materially impact the production quality.
• Promptly respond to the provider queries as required around scribed information.
• Electronic Medical Records Summarizer’s job is to review and summarize patient’s medical information such as attending Physician statements, lab reports, para med exams, and/or other related underwriting information consistent per client specifications.
• They also need to review case narratives & queries on drug interaction and adverse effects on drugs.
• Detect, Interpret and update the treatment related information from the case of the patient which enables to convert physical health information into Electronic Medical Record (EMR).
• Creating precise and informative medical summaries of patients and are backed by medical literature.
• Interaction with managers regarding problem solving and understanding the process.
• Create accurate and informative medical summaries of patients.
• Review medical information such as attending physician statements, lab reports, paramedics exams, and/or other related underwriting information consistent per client specifications.
• Ability to analyze a case of medical malpractice, personal injury and mass tort cases.
• Review case narratives queries on drug interaction and adverse effects on drugs.
• Detect, interpret, and update the treatment-related information from the case which enables the conversion of physical health information into Electronic Medical Record (EMR).
• Perform quality checks by doing case analysis and peer reviews.
• Perform the medical review, validate follow-up request and perform the medical assessment
• Look at each medical record to check for the missing documentation.
• Interact and work with managers regarding problem-solving and understanding the process.
• Prioritize workloads to ensure expedited cases are processed within defined timelines.
• Responsible for the timely completion of individual cases and meeting the SLA for data entry and case analysis activity as per SOP.
• Medical Records Technicians are responsible for organizing and managing patients' health information data.
• They ensure paperwork is properly filled out, verify accuracy and accessibility of files, and are responsible for keeping all files secure.
• Enter all the records that are received in MRD.
• Update the inpatient details for all discharge records.
• Generate the daily, weekly, monthly, annual reports required by the staff of MRD to perform the work.
• Generate any other reports as assigned by the Head of the department.
• To look after the Electronic Medical Records of the hospital.
• Oversee all personnel within their department and ensure that they are properly trained to work efficiently and in accordance with all regulations.
• All medical records are maintained and updated in computerized databases, and it is the responsibility of these managers to properly train all personnel to use software for this purpose.
• Generate frequent reports related to the accuracy of data entered and the efficiency with which these entries create payments for the organization.
• They are responsible for administrative as well as clinical tasks, such as maintaining patient records, preparing patients and rooms for examination, assisting physicians with exams, and performing front-desk tasks.
• Receive and direct phone calls, schedule appointments, check-in patients, obtain necessary patient information to file and update patient records, and ensure all forms and consents are completed by patients.
• Check-out patients, assist with referral processing, and arrange laboratory services.
• Prepare patients for examination, take vitals, and record patients' health history.
• Administer injections and medications and perform routine specimen collection and tests.
• Assist physician with medical treatments, procedures, and exams.
• Manage inventory of medical supplies and equip exam rooms with appropriate supplies.
• Assists physicians/physician assistants/nurse practitioners in medical office settings.
• Generate comprehensive medical records to optimize doctor time.
• Transcribing medical notes from patient-doctor encounter.
• Transcribe comments from recordings provided by the physician.
• Document the patient history including history of present illness, review of systems, past medical and surgical history, family and social histories, medications, and allergies.
• Document the results of laboratory and radiographic studies as dictated by the physician.
• Document the correct time of patient care-related activities, including physician-to-physician communication, family communication, and re-examination of the patient.
• Review medical records and produce an accurate summary of the patient s medical history.
• Verify and review all forms and documents about a case for errors, missing information, legibility; and request follow up information as required.
• Detect, interpret, and update the treatment-related information from the case of the patient which enable to convert physical health information into Electronic Medical Record (EMR).
• Ensure summaries are precise, accurate and are backed by medical literature.
• Interact with managers regarding problem-solving and understanding the process.
• Ensure accurate and documentation of medical history, suspect drugs, and affiliated medications.
• Assess adverse event reports for seriousness, causality, and expectedness as per the appropriate label.
• Verify consistency between the source documents and the narrative summary.
• Healthcare data analysts oversee hospital data management and analytics.
• Responsible for compiling and organizing healthcare data, analyzing data to assist in delivering optimal healthcare management, and communicating their findings with management.
• Interviewing personnel and conducting onsite observations for determining the methods, equipment, and personnel that will be required.
• Analyze data to assist in delivering optimal healthcare management and decision making.
• Developing reports and presentations, solutions or alternative practices.
• Recommending new systems and procedures to management through written reports or presentations.
• Confer with managers to ensure that implemented changes are working.
• Communicate analytic insights to management.
• Recording patients' medical history.
• Request and interpret diagnostic tests.
• Responsible for assisting Doctors in documentation.
• Ensure that patient report and documentation is complete and consents for surgery and procedures are taken.
• Effective communication with patients, family, colleagues and other health care workers.
• Prepare patient files by obtaining personal and health information.
• Maintain patient data records for evaluation and health insurance purposes.
• Listen to the recorded dictation of a doctor or other healthcare professional.
• Transcribe and interpret the dictation into diagnostic test results, operative reports, referral letters, and other documents.
• Review and edit drafts prepared by speech recognition software, making sure that the transcription is correct, complete, and has a consistent style.
• Translate medical abbreviations and jargon into the appropriate long form.
• Identify inconsistencies, errors, and missing information within a report that could compromise patient care.
• A clinical reviewer monitors healthcare documents to ensure compliance before submitting to insurance companies.
• Check medical records for appropriate criteria and provide proper documentation.
• Review clinical trial data as per SOP, protocol, and study specific guidelines.
• Issue and review queries for missing, inconsistent, illegible, or erroneous data; follow queries to resolution.
• Ensure quality in all data cleaning efforts, including external data cleaning, such as lab data review and Serious Adverse Event reconciliation.
• Create ad-hoc listings to review ongoing clinical study data.
• Encoding of study data with standard dictionaries (MedDRA, WHO Drug).
• Assist with maintenance of all relevant clinical trial documentation.
• Interact with various Data Management and other functional area colleagues such as Project Management and Project Coordination, and Site personnel.
• Assist with database lock processes.
• Function in all operational aspects of clinical trials in compliance with GCP regulations, DSG policy and Client company policy.
• Prepare and assemble medical record documentation/charts for physician(s).
• Accompany physician in the patient room to capture and transcribe medical record documentation utilizing electronic medical record applications.
• Ensure medical record compliance by self-documentation attestation.
• Update patient history, physical exam, and other pertinent health information in the patient.
• Prepare and sends all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
• Monitor the duration of basic lab results and screening procedures.
• Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
• Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.