Job Description

Key Responsibilities

• Document patient history, symptoms, examination findings, diagnoses, and treatment plans during patient visits.
• Enter and update patient information in the EHR system.
• Prepare medical notes, including progress notes, consultation notes, and discharge summaries.
• Assist physicians with reviewing medical records and organizing clinical information.
• Document medications, allergies, laboratory results, imaging findings, and procedures as directed by the physician.
• Ensure documentation is accurate, complete, and completed in a timely manner.
• Maintain patient confidentiality and comply with healthcare privacy regulations.
• Coordinate with physicians, nurses, and other healthcare staff when clarification of documentation is required.
• Perform basic administrative and clinical documentation tasks as assigned.

Qualifications

• Bachelor’s degree in Health Sciences, Life Sciences, Medicine, Nursing, or a related field is preferred.
• Strong knowledge of medical terminology, anatomy, and basic clinical concepts.
• Excellent English communication, listening, and typing skills.
• Familiarity with EHR/EMR systems.
• Strong attention to detail and ability to work in a fast-paced clinical environment.
• Previous experience as a medical scribe, medical assistant, or healthcare professional is an advantage.

Key Skills

• Medical terminology
• Clinical documentation
• EHR/EMR proficiency
• Fast and accurate typing
• Attention to detail
• Confidentiality and professionalism
• Communication and active listening
• Time management
• Ability to multitask