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Virtual medical scribe training: Guidelines for new scribes 

Aspiring virtual medical scribes often face the challenge of understanding the complex, fast-paced world of healthcare documentation.

Without the right training, many medical scribes struggle to keep up with the demands of real-time documentation, medical terminology, and Electronic Health Record (EHR) systems.

New scribes may find themselves overwhelmed and unable to keep up with the high expectations of accuracy and speed. This could lead to missed details in patient records, frustrated physicians, and even job burnout.

This guide provides comprehensive training guidelines for new virtual medical scribes, breaking down the skills, tools, and techniques needed to succeed.

From mastering medical terminology to navigating EHR systems, this article will help you build the confidence and expertise to thrive in the growing field of virtual medical scribing.

The job of a virtual medical scribe

A virtual medical scribe helps healthcare providers by documenting patient encounters in real time, allowing the provider to focus on patient care rather than paperwork.

As a virtual scribe, you listen to consultations between the provider and patient through a HIPAA-compliant telehealth platform or recorded audio. 

Additionally, virtual medical scribes are responsible for updating the Electronic Health Record (EHR) system, ensuring all notes are accurate, complete, and compliant with healthcare regulations like HIPAA.

You’ll need to document important information such as:

  • Patient history – The patient’s past and existing medical conditions, family history, and current symptoms.

  • Physical exam findings – Any abnormalities or relevant observations the provider makes.

  • Lab and diagnostic results – Test results such as blood work, imaging, or other diagnostics.

  • Diagnoses – The physician’s assessment of the patient’s condition.

  • Treatment plans – Medications, lifestyle changes, and follow-up instructions.

Insider tip:

To excel as a virtual medical scribe, focus on developing speed and accuracy when working with EHR systems.

Learning common medical terminology specific to the specialty you’re scribing for (e.g., cardiology, OB/GYN) and familiarizing yourself with EHR templates can significantly improve your workflow and efficiency.

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Why are virtual medical scribes important in healthcare 

Virtual medical scribes play a crucial role in healthcare. They streamline the documentation process and allow doctors to focus more on patient care.

Here are some key reasons why medical scribes are important:

1. Improving physician efficiency

Physicians are burdened by administrative work. Virtual medical scribes reduce this burden through medical scribing.

They handle real-time documentation of patient encounters, including histories, diagnoses, and treatment plans. This allows doctors to see more patients and do less paperwork, improving overall productivity.

A good virtual medical scribe will follow these approaches in recording the patient’s histories, diagnoses, and treatment plans: 

A. Histories

What to record: 

  • Chief Complaint: Why the patient is visiting.

  • Past Medical History (PMH): Any previous conditions, surgeries, or hospitalizations.

  • Family History: Medical conditions in close relatives may affect the patient’s health.

  • Social History: Lifestyle factors such as smoking, alcohol use, occupation, and diet.

  • Medication History: Current medications, dosages, and allergies.

  • Review of Systems (ROS): Patient’s response to questions regarding different systems (e.g., cardiovascular, respiratory, gastrointestinal).

Example of good notes from a virtual medical scribe:

  • Chief Complaint: Patient reports shortness of breath and chest pain lasting for two days.

  • Past Medical History: History of hypertension, hyperlipidemia, and coronary artery disease. Coronary stent placed in 2020.

  • Family History: Father had a myocardial infarction at age 55, mother has diabetes.

  • Social History: Smokes 1 pack of cigarettes per day for 15 years, drinks alcohol occasionally, sedentary lifestyle.

  • Medication: Currently taking atorvastatin 20mg daily and metoprolol 50mg twice daily. No known drug allergies.

B. Diagnoses

What to record:

  • The physician’s diagnosis is based on the patient’s history, physical exam, and test results.

  • Include differential diagnoses if the provider lists them (possible conditions being considered).

Example of good notes from a virtual medical scribe:

  • Diagnosis: Likely unstable angina. Rule out myocardial infarction (pending results of cardiac enzymes and EKG).

  • Differential Diagnosis: Consider pulmonary embolism, pericarditis, or costochondritis if cardiac etiology is ruled out.

C. Treatment Plans

What to record:

  • Medications prescribed, including dosage and instructions.

  • Diagnostic tests ordered (e.g., blood work, imaging).

  • Any referrals (e.g., cardiologist, specialist).

  • Lifestyle recommendations (e.g., dietary changes, exercise).

  • Follow-up instructions, including when the patient should return for further care.

Example of good notes from a virtual medical scribe:

  • Medications: Initiate nitroglycerin sublingual 0.4mg as needed for chest pain. Continue atorvastatin and metoprolol. Consider adding aspirin 81mg daily pending lab results.

  • Diagnostic Tests: Order cardiac enzymes (troponin) and an EKG for further evaluation. If stable, consider a stress test.

  • Referral: Refer to a cardiologist for further evaluation and management.

  • Lifestyle Recommendations: Advised patient to stop smoking and limit sodium intake to 2 grams per day and encouraged moderate physical activity after clearance from cardiologist.

  • Follow-Up: Return to the clinic in one week or sooner if symptoms worsen.

Insider tip:

A good virtual medical scribe organizes notes clearly and concisely using bullet points or short, structured sentences. Stick to the facts, avoid interpretation, and always document in the present tense. 

This helps ensure the patient records are understandable for the provider and any future reference.

Additionally, being familiar with medical terminology will help you keep up with the provider’s pace and ensure you can accurately document your patient records.

2. Enhancing the quality of patient carevirtual medical scribe medical patient care

With medical scribes handling documentation, physicians can give more attention to their patients, leading to improved patient satisfaction and quality of care. Instead of typing and recording data, providers can better focus on diagnosing and treating their patients. 

With improved patient-provider interaction, the doctor can gain a better understanding of treatment plans and address more concerns during visits.

For example, Dr. Sarah, a cardiologist, typically spends 10-15 minutes per patient managing their health concerns, but an additional 20 minutes after each visit, updating the patient’s records in the EHR system. 

With the help of a virtual medical scribe, Dr. Sarah no longer needs to handle the documentation herself. During patient visits, she can now focus entirely on listening to the patient’s concerns, asking deeper questions about symptoms, and explaining treatment plans in detail.

3. Reducing physician burnout

Documentation tasks are often a leading cause of burnout for healthcare professionals. Virtual medical scribes relieve this pressure, helping doctors finish their workday on time and avoid after-hours charting. 

Doctors can have a better work-life balance with the help of virtual medical scribes. A less-stressed physician is more attentive and can provide higher-quality care, improving patient experience and outcomes.

Example scenario:

For instance, Dr. James, a general practitioner, had been experiencing burnout due to long hours spent charting after his clinic hours. On average, he spent an extra 2-3 hours each evening catching up on EHR documentation, cutting into his family time and personal life.

After hiring a virtual medical scribe, Dr. James could complete his daily patient visits without needing to stay late at the clinic. The scribe handled all the charting and administrative work in real time during the appointments. 

Dr. James started finishing work on time, regaining time to relax and spend with his family. Feeling more rested, he noticed an improvement in his attentiveness during consultations, and patient feedback reflected a higher level of satisfaction with the care he provided. 

As his stress levels dropped, so did his chances of making mistakes during patient visits, improving overall care quality and patient outcomes.

4. Accurate and timely documentation

A virtual medical scribe ensures that patient records are documented in real-time and accurately, which is critical for quality care, legal protection, and compliance with healthcare regulations like HIPAA.

Properly maintained and compliant records prevent legal issues and help maintain trust between patients and the healthcare system. It also ensures you can securely handle sensitive patient information.

Example scenario:

In a busy hospital setting, Dr. Lee, an emergency room physician, treated a patient with a complicated medical history and multiple medications. Thanks to the virtual medical scribe documenting the encounter in real time and ensuring that all entries comply with HIPAA regulations, Dr. Lee could focus entirely on diagnosing and treating the patient.

A few months later, the hospital faced a legal issue involving this patient, whose family claimed that specific instructions were not given during their visit. 

Because the medical scribe had documented everything accurately, including the doctor’s treatment plan, medication changes, and the patient’s instructions, the hospital could provide complete, detailed records showing the care was appropriate and compliant with healthcare regulations.

5. Improved workflow in busy healthcare settings

In fast-paced environments such as emergency rooms or large clinics, virtual medical scribes can help manage patient flow by keeping patient records up-to-date and ensuring that no essential details are missed during patient visits.

Example scenario: 

In a busy urban hospital’s emergency department (ED), Dr. Emily is handling multiple patients simultaneously. The department sees a high volume of patients, ranging from those with minor injuries to critically ill individuals. 

Each patient’s visit must be thoroughly documented in the Electronic Health Records (EHR), but the fast-paced environment leaves little time for Dr. Emily to focus on paperwork.

Dr. Emily’s virtual medical scribe is remotely connected, documenting all patient encounters in real time.

For example, when Dr. Emily assesses a patient with chest pain, the scribe immediately updates the patient’s history, records the physical exam findings (such as heart rate, blood pressure, and lab results), and notes the ordered diagnostic tests, like an EKG or blood tests. 

The medical scribe also captured Dr. Emily’s diagnosis and treatment plan, which included administering nitroglycerin and ordering a follow-up.

Insider tip for new virtual medical scribes:

Virtual medical scribes are not just data entry clerks; they are integral to creating a seamless healthcare experience. To be effective, virtual medical scribes must build strong communication with the rest of the healthcare team. They must understand the workflow and proactively manage patient data accurately and efficiently.

Overview of training as a virtual medical scribe

Training to become a virtual medical scribe involves acquiring medical knowledge and technical skills, which help you ensure accuracy and efficiency in medical scribing. 

Here’s an overview of what medical scribing training typically includes:

1. Medical terminology training

  • Objective: To gain a deep understanding of medical terminology, anatomy, and common conditions to accurately document patient histories, symptoms, diagnoses, and treatment plans.

  • Training Method: Online courses, flashcards, and quizzes on platforms like Coursera, edX, or Meditec.

2. Electronic Health Records (EHR) system training

  • Objective: Learn how to navigate the specific EHR system used by the healthcare provider (such as Epic, Cerner, or AthenaHealth).

  • Training Method: Hands-on tutorials and simulation programs to familiarise with entering data, creating charts, and managing patient records efficiently.

Insider Tip: Master EHR keyboard shortcuts and practice navigating through the system to increase your speed.

3. Documentation skills

  • Objective: Develop the ability to document patient encounters in real-time, including physical exams, diagnostic results, and treatment plans.

  • Training Method: Mock patient encounters where you practice documenting patient-provider interactions. Some programs may offer direct scribing experience under supervision.

Insider tip: Create templates for common medical conditions to speed up documentation and ensure consistency.

4. HIPAA compliance and data privacy

  • Objective: Understand healthcare regulations like HIPAA (in the US) to ensure patient data is handled securely and confidentially.

  • Training Method: Online courses on compliance standards, quizzes, and scenarios to test your underestanding of privacy laws.

5. Typing and Listening Skills Developmentvirtual medical scribe medical writing

  • Objective: Improve your typing speed and accuracy while listening to complex medical information.

  • Training Method: Typing practice software, listening to medical dictations, and transcribing them as accurately and quickly as possible.

Insider tip: To keep up with real-time documentation, aim for a typing speed of 60+ words per minute with high accuracy.

6. Specialty-specific training

  • Objective: For those scribing in specialised fields (e.g., cardiology, OB/GYN), develop a deeper understanding of terminology and workflows specific to that specialty.

  • Training Method: Specialty-specific training modules that cover common conditions, medications, and procedures in your chosen field.

Insider tip: Focus on mastering common diagnoses, tests, and medications in the specialty you’re working in to boost your confidence and efficiency.

7. On-the-job training

  • Objective: Apply your skills in real patient encounters under supervision.

  • Training Method: After completing initial training, you may work under experienced scribes or supervisors who provide feedback on your performance. Some companies may offer shadowing opportunities.

Insider tip: Seek constructive feedback from supervisors to continuously improve your accuracy, speed, and understanding of medical workflows.

Duration of medical scribe training program

A medical scribe training program typically lasts from a few weeks to a few months, depending on the complexity of the medical specialty, the provider’s workflow, and the familiarity of the virtual scribe with medical terminology and EHR systems.

Insider tip for medical scribe training:

Maximize your learning by going through a medical scribe certification exam. You can also practice with mock scribing sessions and using EHR simulation tools. The more you simulate real patient encounters, the more prepared you’ll be when handling live sessions.

Additionally, while you’re undergoing medical scribe training, don’t hesitate to ask for mentorship or guidance from seasoned medical scribes. They can offer valuable insights and tips for success in your medical scribe training and working in healthcare environments.

Career opportunities for virtual medical scribes

After undergoing a medical scribe certification exam and working professionally as a scribe, you can choose to advance to any of the following advanced roles:

1. Medical transcriptionistvirtual medical scribe medical transcriptionist

A medical transcriptionist listens to voice recordings made by healthcare professionals and converts them into written reports.

  • Why it’s a fit: Virtual scribes are already skilled in medical documentation and terminology, making the transition to transcription seamless.

  • Opportunity: Many hospitals, clinics, and healthcare outsourcing companies hire medical transcriptionists, and it’s a flexible remote job like scribing.

2. Health Information Management (HIM) Specialist

HIM specialists manage patient health information, ensuring records are accurate, secure, and compliant with healthcare regulations (e.g., HIPAA in the US).

  • Why it’s a fit: Virtual scribes are familiar with Electronic Health Record (EHR) systems and healthcare documentation protocols, which are essential for this role.

  • Opportunity: Hospitals, clinics, and large healthcare providers hire HIM specialists to oversee patient records, compliance, and data management.

3. Medical Coding and Billing Specialist

Medical coders translate healthcare diagnoses, procedures, and services into universal medical codes used for insurance claims.

  • Why it’s a fit: Virtual scribes’ exposure to medical terminology, diagnoses, and treatment plans makes learning medical coding straightforward.

  • Opportunity: Medical coding and billing specialists are in high demand in hospitals, private practices, and healthcare outsourcing firms. Many companies offer remote roles.

4. EHR Trainer/Consultant

EHR trainers teach healthcare staff to use Electronic Health Record systems effectively, ensuring proper documentation and efficient workflows.

  • Why it’s a fit: Virtual scribes are already proficient in EHR navigation and workflows, making them well-suited to train others in best practices.

  • Opportunity: Large healthcare providers, hospitals, and clinics need trainers to onboard new staff and optimize EHR use. You could also work for an EHR vendor, helping clinics implement their systems.

5. Medical Assistant

Medical assistants support healthcare providers with administrative and basic clinical tasks, including documenting patient information, scheduling, and preparing patients for exams.

  • Why it’s a fit: Virtual scribes have strong skills in patient documentation and understanding of medical procedures, which are key components of a medical assistant’s role.

  • Opportunity: While some in-person medical scribe training may be required, medical assistants are in demand at outpatient facilities, primary care offices, and specialty clinics.

6. Healthcare administrative coordinator

Healthcare administrative coordinators oversee patient flow, manage healthcare records, and support clinical staff with scheduling and documentation.

  • Why it’s a fit: Virtual scribes’ knowledge of EHR systems and familiarity with medical office workflows make them valuable in administrative roles.

  • Opportunity: Hospitals, clinics, and healthcare practices employ administrative coordinators, and remote roles may be available with telemedicine providers or healthcare service companies.

7. Clinical Documentation Improvement (CDI) Specialist

CDI specialists review and improve the accuracy and completeness of clinical documentation to support proper coding, reimbursement, and patient care.

  • Why it’s a fit: Virtual scribes excel at accurately documenting patient encounters, making them strong candidates for CDI roles.

  • Opportunity: Many hospitals and healthcare organizations hire CDI specialists to ensure compliance and accurate clinical data for audits and insurance purposes.

About Nathan Barz, CEO, DocVA

Nathan Barz is dedicated to integrating virtual assistants into healthcare practices across the United States, Canada, and beyond. With firsthand experience in healthcare, he has successfully implemented virtual medical assistant services in numerous practices, improving profitability and service quality and reducing staff burnout. Nathan firmly believes virtual assistants are the solution to addressing staffing shortages and economic challenges in the healthcare industry.

View all posts by Nathan Barz, CEO, DocVA