Aspiring medical scribes often dread navigating the complex world of healthcare documentation. This is totally normal if you’re feeling like you’re the only one. From medical jargon to real-time charting, it’s easy to feel overwhelmed without the right guidance.
You risk falling behind without a clear understanding of a virtual medical scribe job, especially in cardiology or OB/GYN. You’ll need speed, accuracy, and adaptability to different Electronic Health Records (EHR) systems. These essential skills can make or break your success in the field.
If you’re nervous about starting as a medical scribe, this article provides comprehensive guidelines for anyone starting or looking to refine their skills.
What’s a virtual scribe medical job?
A virtual medical scribe’s job involves documenting patient encounters in real-time for healthcare providers. This boosts their productivity and helps them focus more on patient care and increase patient satisfaction.
As a virtual scribe, you’ll listen to conversations between the physician and their patient via a telehealth platform or audio files. You will record important details from their conversation, such as patient history, diagnoses, symptoms, and treatment plans, in the Electronic Health Records (EHR) system.
Insider tip for aspiring virtual scribes:
Remember that your success heavily relies on two things: speed and accuracy. So, if you want to advance your career as a virtual medical scribe, learn the keyboard shortcuts of the EHR system you’ll be using. This can help save you time when documenting patient encounters.
While some companies will pay for your training in using that specific EHR app, mastering it beforehand will help you stand out from other applicants. It will also help you learn the basics or ins and outs of patient care.
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Tasks of a virtual medical scribe
If you’re going to work as a remote medical scribe in cardiology, for example, here are the key tasks you need to handle:
1. Document patient histories
Virtual scribes need to document detailed patient histories, current symptoms, medical history (especially heart-related conditions), family history of cardiac disease, medications, and lifestyle factors (ex. smoking). To be effective, you can develop templates for common conditions such as atrial fibrillation, heart failure, or coronary artery diseases to speed up your documentation process.
2. Record vital signs and test results
Document vital signs such as blood pressure, heart rate, and cholesterol levels. You’ll also need to record results from diagnostic tests such as EKG, echocardiograms, stress tests, and angiograms.
Before recording the vital signs, we highly recommend you familiarize yourself with the normal and abnormal ranges of cardiovascular-related test results. This will help you recognize critical details quickly and document them accurately.
3. Document the physician’s physical exam findings
Accurately record the cardiologist’s findings from the physical exam, such as the presence of murmurs, abnormal heart sounds, or signs of congestive heart failure (ex., Swelling in the legs).
Learn the basics of cardiac auscultation terminology so you can better understand, and document findings related to heart sounds, murmurs, and other key exam details.
4. Input diagnoses and treatment plans
Document the cardiologist’s diagnoses (ex., Myocardial infarction, arrhythmia, or congestive heart failure) and the recommended treatment plan, which may include medications, lifestyle changes, or further tests.
To document effectively, learn the common cardiovascular medications such as beta-blockers, statins, ACE inhibitors, and anticoagulants. This will help you document treatment plans more effectively and understand their purpose.
5. Transcribe patient education and follow-up instructions
Record any education or advice provided to the patient regarding heart health, including diet, exercise, medication adherence, and follow-up appointments.
We also recommend you keep a list of common cardiology patient education points (like lifestyle modifications for heart diseases) to streamline documentation during pateint visits.
How do virtual medical scribe services work
Some companies (or agencies) provide virtual medical scribe services to large hospitals and healthcare facilities. That means the physicians or healthcare professionals pay the provider to help them hire a virtual scribe. Here’s how the process usually works:
1. Remote connection
Compared to traditional medical scribes, a remote medical scribe works remotely. They link remotely to the healthcare provider’s practice via a secure platform, often using a video conferencing tool or an EHR-integrated system.
2. Real-time documentation
During the consultation, the virtual scribe listens to the discussion between the physician and the patient in real time. Virtual scribes take notes and update the patient’s medical records, entering their symptoms, medical history, diagnoses, lab results, and treatment plans into the EHR system.
3. EHR updates
After the patient visit, the remote medical scribe listens again to the recorded conversation to ensure the recorded details are all accurate and relevant. They will also take care of other admin tasks, such as updating the patient charts, documenting follow-ups, and submitting referrals.
4. Data accuracy and compliance
Just like traditional medical scribes, virtual medical scribes must ensure the information entered complies with healthcare regulations such as HIPAA (in the US) or other privacy standards, depending on the country where they reside.
Insider tip for aspiring virtual scribes
To be an effective virtual scribe, focus on familiarizing yourself with the EHR’s workflow and important medical terminology used in the clinic for which you’re applying. For example, if you want to work at an OB Gyne clinic, you’ll want to memorize what “GPA” means.
Gravida (G) stands for the number of pregnancies, Para (P) for the number of births, and Abortus (A) for the number of miscarriages or abortions. During one of the patient encounters, you may hear the doctor say G2P1A1, which means 2 pregnancies, 1 birth, and 1 miscarriage/abortion.
Aspiring virtual medical scribes can learn this information from a medical transcription or coding course for virtual scribes in Coursera, Meditec, or Alison.
Hard and soft skills of virtual medical scribes
To excel as a virtual medical scribe, you’ll need a set of hard and soft skills. Of course, realistically speaking, you can’t acquire them all in a matter of weeks. These may take months or at least 2 years to master.
Nevertheless, it’s important that you know what skills you must sharpen before you start applying for positions in clinics or hospitals. This will give you a better sense of direction when you start specialty training or studying courses about medical transcription, terminology, scribing, and basic patient care.
Hard skills
Medical terminology – Virtual medical scribes need to have a deep understanding of medical terms, anatomy, and common conditions is essential for accurate documentation.
EHR proficiency – Familiarity with various EHR systems such as Epic, Cerner, or Athenahealth helps you efficiently document patient encounters
Typing speed and accuracy – Since you’ll probably be documenting in real time, typing quickly and accurately is crucial.
Attention to detail – Ensuring every medical note is precise, complete, and free of errors is important for legal and clinical reasons.
Understanding of HIPAA – Virtual scribes must be well versed in healthcare privacy laws such as HIPAA to handle sensitive information about the patient.
Medical documentation – The ability to create structured, concise, and legible patient notes based on provider-patient interactions.
Soft skills
Active listening – Virtual scribes may document in real time, so a focused and attentive listener is essential.
Time management – Managing multiple patients’ documentation efficiently while maintaining quality is critical. They also need better time management to handle administrative tasks, so the doctors can focus better on patient care.
Adaptability – Medical environments can be fast-paced, and you may need to adapt to different specialties or healthcare provider preferences.
Communication – Strong written and verbal communication skills help virtual scribes document accurately and maintain clarity.
Stress management – Working under pressure in a real-time environment requires virtual scribes to have the ability to stay calm and composed.
Insider tip for aspiring medical scribes
To improve your soft skills, try practicing mock patient encounters by listening to medical podcasts or sample consultations online. Document them as if you were a virtual scribe, and then review your notes for accuracy and speed. For hard skills, consider using EHR simulation software to get hands-on experience with the systems. This way, you’ll be better prepared when you start working!
Overcoming challenges as a virtual medical scribe
Overcoming challenges as a virtual medical scribe requires both strategic preparation and adaptability. Here are some common challenges and how to tackle them:
1. Learning medical terminology
Medical jargon, abbreviations, and complex terms can be overwhelming to learn, especially if you have no prior experience in the healthcare field.
Solution: Enroll in online courses or use apps designed to improve your medical vocabulary, such as Quizlet or Medical Terminology for Dummies. Create flashcards to memorize important terms. Over time, you’ll become more familiar with common medical phrases.
2. EHR navigation
Each EHR system has its own interface, which can be confusing at first.
Solution: Take advantage of tutorials, user guides, or free EHR training programs like those from Practice Fusion or EpicCare. Practicing in a demo environment will help you gain confidence and speed.
3. Working remotely
As a remote scribe, communication barriers may arise, and isolation can lead to feeling disconnected from the healthcare team.
Solution: Maintain regular communication with the healthcare provider through messaging platforms, video calls, or email. Join online scribe communities to share insights, troubleshoot issues, and gain support from fellow scribes.
4. Handling fast-paced environments
In a busy clinic or hospital, patient encounters happen quickly and documenting everything in real time can feel stressful.
Solution: Stay organized by developing shortcuts or templates for common medical documentation, like physical exams or reviews of systems. These templates will help you work faster without sacrificing accuracy. Time management techniques such as the Pomodoro method can also help you maintain focus.
5. Maintaining accuracy under pressure
Speed is critical, but you also need to ensure that your documentation is 100% accurate.
Solution: Focus on your active listening skills. Try summarizing notes in your head before typing to ensure you capture the right information. Double-check entries during downtime to catch mistakes before the provider reviews them.
6. Adapting to different providers
Each healthcare provider has a unique communication style and may prefer specific documentation methods.
Solution: Be adaptable. Take notes on the provider’s preferences and ask for feedback to improve. The more aligned you are with the provider’s style, the more seamless your workflow will become.
Insider tip for aspiring scribes
When you’re starting out, prioritize learning common patient scenarios in the specialty you’re scribing for (Ex. cardiology). Understanding the typical flow of the typical visits will give you a head start in recognizing patterns in documentation, helping you become more efficient over time. Don’t hesitate to seek mentorship from experienced scribes or your supervisors if you encounter challenges — they’ve likely faced the same issues!