An internal medicine scribe supports internists by managing detailed documentation for diagnosing and treating patients. Since internal medicine covers a wide range of conditions, this role can be really challenging. If you’re considering a career as an internal medicine scribe, keep reading to explore key responsibilities, skills, and terminology needed to succeed.
Internal medicine medical scribes – what do they actually do?
The primary responsibility of an internal medicine scribe is to document patient encounters. Internists treat a wide variety of chronic and acute illnesses including hypertension, diabetes, infections, cardiovascular disease, and respiratory conditions.
During patient appointments, the scribe records the history of present illness, review of systems, physical exam findings, lab results, imaging studies, and treatment plans. These notes are entered directly into electronic health records (EHRs) in real-time. So, by managing documentation, the internal medicine scribe allows physicians to focus more on patient care and clinical decision-making.
Skills needed for the job
To perform well as an internal medicine medical scribe, you need to have a strong foundation in medical terminology and clinical processes. Since internal medicine covers many organ systems and diseases, scribes must understand terms related to cardiology, pulmonology, endocrinology, gastroenterology, and infectious diseases.
Fast and accurate typing is simply essential for internal medicine scribes to keep up with physicians, while familiarity with EHR systems and medical software helps improve efficiency and reduce errors. Equally important is strong attention to detail, ensuring that every aspect of the patient’s visit is accurately documented. Last but not least, strong listening and communication skills are also a must, as scribes often need to clarify ambiguous information with physicians without interrupting the flow of the appointment.
Important terminology for internal medicine scribes
Understanding core internal medicine terminology is key for effective documentation. Some commonly used terms include:
- Hypertension – high blood pressure
- Congestive heart failure – a condition where the heart does not pump blood effectively
- Chronic obstructive pulmonary disease (COPD) – a progressive lung disease
- HbA1c – a blood test that measures average blood glucose levels over time
- Antibiotic stewardship – responsible use of antibiotics to combat resistance
Familiarity with these and other terms allows internal medicine medical scribes to accurately record diagnoses, treatment plans, and follow-up instructions.
Why choose a career as an internal medicine medical scribe?
If you’re interested in healthcare, becoming an internal medicine scribe gives you valuable hands-on experience in a fast-paced, diverse clinical setting. It’s a great opportunity to get hands-on experience with a variety of medical conditions and treatment methods.
Working alongside internists allows scribes to gain valuable insights into patient care, clinical workflows, and medical decision-making. This experience can be a stepping stone toward future careers in medicine, nursing, or other healthcare professions.
The takeaway
Internal medicine scribes are essential in supporting internists by delivering accurate, detailed, and timely clinical documentation. The role requires specialized knowledge of internal medicine terminology, excellent typing and organizational skills, and the ability to work efficiently in a clinical environment.
If you’re detail-oriented and interested in building a career in healthcare, take a look at our available medical scribe job openings.
