Medical Scribe Certificate

Program Information

A Medical Scribe is a member of the health care team who, under the direction of a licensed care clinician, assists with point-of-care medical documentation. Medical Scribes use the electronic health records to provide real-time clinical documentation allowing the healthcare provider to focus on the patient. Medical Scribes may also gather test results and complete forms needed for patient care. Scribes record the patient’s history, physician’s interaction with the patient, procedures, lab results and other information.

Program Outcomes

Graduates will be able to:

• Demonstrate how electronic health records are used in outpatient and inpatient settings;
• Partner with medical provider to deliver efficient patient care through documentation;
• Use proper rules of grammar, punctuation, numbering, abbreviations, acronyms, and metric measurement rules in medical documentation;
• Define and use medical terminology related to pathology, diagnostic and treatment procedures of each body system;
• Explain the organization of the body and how each system functions including anatomical reference systems;
• Explain the confidentiality and basic legal aspects of a patient’s medical record;
• Understand and apply common pharmacology, diagnostic, and medical charting requirements in the electronic health record (EHR);
• Understand and select basic medical codes retrieved from a list to match medical visit at time of visit;
• Apply scribe workplace fundamentals through directed multimedia scenarios;
• Demonstrate professionalism, etiquette, and personality of a functioning and successful scribe, including HIPAA and medico-legal requirements; and
• Demonstrate professional and ethical conduct in oral and written communication.

Special Program Requirements

In addition to the program requirements, students must meet the following conditions in order to graduate:

1. College Cumulative GPA Requirement: cumulative grade point average (GPA) of credits attempted and completed at CLC must be at least 2.0;
2. College Technical Core GPA Requirement: cumulative GPA of credits attempted and completed towards the technical core of the diploma or degree must be at least 2.0;
3. Residency Requirement: students must complete 25% of their credits at Central Lakes College.

Career Opportunities

Medical Scribes positions are ideal for individuals interested in medical documentation, clerical work and being part of a care team. A medical scribe is part of the care team, but with no hands-on patient care. Medical scribes must know and apply medical documentation requirements, use information technology, apply medical terminology and human anatomy, and have an understanding of the basics of medical coding. A medical scribe needs to be adaptable, detailed oriented, analytical, versatile and be able to anticipate the needs of the medical providers they work with. They are a part of the care team and the health information team, working closely with specialists in orthopedics, rheumatology, urology, pain management and other specialty fields.