What is a virtual medical scribe and how to know if you need one
Virtual medical scribing has been the rave among physicians since the COVID-19 pandemic. And the demand for them seems to be going nowhere, based on the rise of physician burnout due to administrative tasks.
This is not surprising, as virtual medical scribes are more than just transcription professionals. You see, they’re just like your productivity partner in the medical field — having one can help you do your job better. That said, finding the right virtual scribe is hardly a walk in the park. Before hiring one, you need to understand how they work, so you can determine their qualities and skills that align with your needs at the clinic.
This article is for healthcare providers and executives who are very curious about the benefits of virtual medical scribing.
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What is virtual medical scribe: Definition and overview
Let’s face it: not every doctor is skilled at multitasking, especially when one of the tasks involves actively listening to patients. This is where a virtual medical scribe comes in to help. A virtual medical scribe helps you carry the heavy load of EHR documentation. They listen to your patient visit using HIPAA-approved tools and makes sure to enter correct, accurate notes into your clinic’s Electronic Health Records (EHR) system.
What do virtual scribes document? 
Virtual scribes record the following pieces of information:
Patient histories. Chief complaints, symptoms, and relevant background.
Examination findings. Physical assessments or observations by the doctor.
Diagnoses – Any conditions or medical conclusions.
Treatment plans. Prescribed medications, procedures, or follow-ups.
Orders. Lab tests, imaging, referrals, and other orders for the patient’s care.
Virtual scribing insider tip
Virtual scribes can also assist with documenting billing codes such as ICD-10, which can help ensure accurate and timely billing for your practice. This saves you time in administrative tasks and reduce errors in claims.
How do virtual medical scribes train?
Virtual medical scribes typically undergo specialty training programs that cover both medical terminology and EHR systems. Here are some areas in which a virtual scribe usually trains:
1. Medical terminology and anatomy
Scribes need a solid understanding of medical terms, abbreviations, and anatomy to accurately document patient encounters. This is why a virtual scribe familiarizes medical language, body systems, and common clinical conditions.
Medical terms – They learn the vocabulary doctors use from the basic (ex. hypertension) to more complex terms, including jargon from other specialties.
Body systems – Understanding how different organs and systems (ex. Cardiovascular, respiratory, or musculoskeletal) work together helps scribes accurately document physical exams and diagnoses.
Pathophysiology – A background in disease processes helps scribes document not just symptoms but also their potential causes and the implications for treatment.
Example: A scribe documenting in an oncology clinic needs to know terms related to cancer staging, chemotherapy, and radiation treatment, as well as common lab results like tumor markers.
2. EHR systems
Virtual scribes are trained on the specific EHR system your clinic uses, whether it’s Epic, Cerner, or Athenahealth. A virtual scribe usually learns the following:
System navigation. They learn to quickly and efficiently move through the EHR interface, entering data in the right sections and locating important information about the patient(s).
Templates and customization. Scribes are also trained to use charting templates that streamline documentation for the typical visits (Ex. physical exams and follow-up consultations). They also learn how to adjust templates to match the physician’s preferences.
Order entry and results review. Many scribes assist with entering orders for labs, imaging, or medications. They must also know how to check and record results in the system for follow-up.
Example: For practices using Epic, scribes are trained to use features such as SmartPhrases to quickly document common clinical notes, reducing charting time for providers.
3. Charting practice 
One of the most important parts of training is real-time documentation. Virtual scribes practice by doing the following:
Simulating patient encounters – They listen to audio recordings of patient visits or engage in live practice sessions to learn how to capture key details such as symptoms, history, exam findings, and diagnoses.
Focus on accuracy and speed – Documentation must be both fast and precise. Training often includes feedback sessions where experienced scribes or trainers review charts or correct errors, ensuring quality standards are met by the trainee.
Learning different visit types – Scribes practice documenting various patient encounters, including initial consultations, follow-up visits, urgent care visits, and specialty consultations.
Example: Medical scribes might be trained on how to document a visit where a patient presents with chest pain, including noting vital signs, physician observations, and potential diagnoses such as myocardial infarction or angina.
4. Compliance and privacy training
Virtual scribes must strictly adhere to healthcare regulations, especially regarding patient privacy and confidentiality. Training includes:
Health Insurance Portability and Accountability Act (HIPAA) – Scribes learn HIPAA requirements such as handling patient information securely, avoiding breaches, and making sure only authorized personnel access sensitive data.
Data security – Medical scribes are trained on how to access EHR systems safely, following protocols to protect against cyber threats. They are trained to use secure logins, encryption, and password updates.
Documentation ethics – During training, medical scribes also learn the importance of unbiased, factual charting. This help them avoid adding subjective opinions or extraneous information to medical records.
Example: Virtual scribes learn not to discuss patient information in unsecured environments such as through personal emails or unprotected communication channels to ensure compliance with legal requirements.
5. On-the-job training
Once a virtual scribe as completed their first phase of training, it’s time to put their theoretical know-how to test. To do this, they often apply or volunteer to get on-the-job experience. During this phase, aspiring medical scribes may do these tasks to gain more practical experience:
Shadowing experienced scribes – New scribes observe how more seasoned scribes handle live patient visits. Through this, they can learn how to adapt to the documention style of the clinic or healthcare provider.
Mentorship and feedback -New scribes may also work with a mentor to get real-time feedback on their documentation skills. By getting this feedback, they can learn how to capture accurate and only relevant information from the patient encounters.
Continuous improvement – Even after completing initial training, scribes often participate in ongoing education to stay updated on new charting methods, software updates, and best practices in documentation.
Example: A scribe working in a cardiology clinic might get OJT on documenting EKG results or interpreting specific cardiology tests, enhancing their ability to support the physician.
Virtual scribing insider tip
Make sure your virtual medical scribe services provider gives an ongoing performance review and access to updated training to your assigned scribe. This will keep them sharp and maintain high documentation standards for your standards.
How virtual medical scribes improve efficiency
Virtual scribes can improve your workflow’s overall productivity and help you focus better on patient care. Here’s how they do it:
1. Reducing administrative burden
With a virtual scribe handling the bulk of your documentation, you can spend less time paperwork after hours or “pajama time.” This helps free up your evenings and weekends that would otherwise be spent on charting. Your work-life balance will finally improve and you’ll less likely be burnout.
Example: Instead of spending 2-3 hours each day after clinic catching up on notes, the provider can focus on reviewing patient charts or attending to more complex cases. This increases your overall patient care quality and satisfaction.
Insider Tip: A medical scribe can help with other tasks like documenting billing codes and generating referral letters, further reducing your admin workload.
2. Optimizing appointment flow
Scribes keep track of the flow of each patient encounter, ensuring smooth transitions between visits. This involves:
Updating the patient’s chart in real-time, so it’s ready for you to review by the end of the visit.
Preparing the chart with relevant details before the appointment, ensuring that critical information is available when you walk into the room.
Keeping a checklist of follow-up tasks (like lab results or imaging) so you won’t need to manually track these items later.
Example: A well-prepared chart allows the HP to move quickly from one patient to the next without delays, reducing overall wait times.
Insider Tip: Instruct your scribe to prepare charts before each appointment, including important details from previous visits, making it easier for the provider to jump straight into the discussion.
3. Improving documentation accuracy
Since scribes are trained to document as you speak, they can ensure the record accurately reflects the details of the visit. This helps reduce the risk of missing critical information or having incomplete charts.
Additionally, you can have the peace of mind that your patient charts are detailed enough to meet coding and billing requirements, reducing claim denials and ensuring compliance.
You can also capture the full complexity of a patient’s condition, which is essential for both treatment and accurate billing.
Example: Accurate documentation helps support higher-level billing codes, ensuring the clinic is properly compensated for the care provided.
Insider Tip: Encourage your scribe to focus on accuracy during the patient encounter to reduce the need for corrections later. This can save you time on chart reviews and reduce discrepancies in patient records.
4. Reducing your cognitive load
With a scribe handling the documentation, you can direct your full attention to the patient, improving the quality of care. You can concentrate on patient interactions, assessments, and decision-making without multitasking between documentation and care.
Plus, you can eliminate distractions to navigating EHRs and inputting data, which can slow down your consultation and lead to errors.
Example: Providers are free to engage with patients, ask more in-depth questions, and make clinical decisions without worrying about the documentation backlog.
Virtual scribing insider tip: Work with your scribe to develop shorthand or standard documentation practices for common conditions, so they can quickly and accurately capture repetitive elements of patient visits without interrupting the provider’s workflow.
5. Supporting compliance and timely chart completion
Scribes ensure your charts are completed and closed promptly, reducing the risk of incomplete records. This helps you meet deadlines for submitting charts, reducing the risk of non-compliance or delays in billing.
You can also rest assured that your documentation reflects the most up-to-date information for each patient, which is crucial in time-sensitive medical cases.
Example: A chart that is completed during or immediately after the visit can be reviewed and signed off quickly, allowing the clinic to stay on top of documentation and billing cycles.
Virtual scribing insider tip: Set clear expectations for your scribe to finish charting within a specific timeframe (e.g., by the end of the day), ensuring timely record completion and improving workflow efficiency.
