Internal Medicine: Certified Medical Scribe Specialists

Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. Internists are especially skilled in the management of patients who have multi-system disease processes. Internists care for hospitalized and ambulatory patients and may play a major role in teaching of future doctors in training and medical students.  They are the front-line of medical care in a hospital.  Because internal medicine patients are often seriously ill or require complex investigations, internists do much of their work in hospitals.  However, Internists generally have outpatient ambulatory practices involving long-term care, preventative care, and occasionally, Urgent Care.  Internists often have subspecialty interests in diseases affecting particular organs or organ systems.  In certain circumstances, due to physician shortages, internists may also staff emergency rooms in rural or suburban hospitals.  Qualified providers of general adult internal medicine include:

  1. Internists: These are physicians have the highest level of training in dealing with acute general medical problems in adults, however, also have the ability to deal with outpatient and ambulatory patient  care as part of their practice.
  2. Hospitalists practice in the medical care of acutely ill hospitalized patients.  The scope of hospital medicine includes acute patient care, teaching, research, and executive leadership related to the delivery of hospital-based care. Hospital medicine is a specialty organized around a site of care (the hospital), rather than an organ (like cardiology).
  3. Family Practice: Many family practitioners practice general adult medicine in an outpatient and inpatient setting.
  4. Nurse Practitioner
  5. Physician Assistant 

Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care. 

Internal Medicine Certified Medical Scribe Specialists are instrumental in the function of that physician’s office.  They become a vital part of a healthcare provide team and can provide the following functions:

  •  Administrative (As directed by the Supervising Physician): 
      1. Using computer applications and electronic medical records (EMR)
      2. Handling correspondence with patients and other healthcare providers
      3. Answering telephones, scheduling appointments, and greeting patients
      4. Scribing, updating and filing patient medical records
      5. Assisting with coding and payer-insurance forms
      6. Helping the staff arrange for hospital admissions and transfers
      7. Helping the staff arranging radiologic and laboratory services
  • Clinical (As directed by the Supervising Physician): 
      1. Scribe medical histories, physical examinations, and test results into EMR
      2. Preparing patients for examination
      3. Assisting the physician during exams, as directed
      4. Reinforcing physician instructions about medication, nutrition, and lifestyle changes
      5. Authorizing prescription refills as directed by the physician, across the healthcare enterprise
      6. Scribe medical histories, physical examinations, and test results into EMR
      7. Prepare procedure trays as directed by a physicians
      8. Authorizing prescription refills as directed by the physician
        *CMS recognizes Certified Medical Scribe Specialists (CMSS) toward pended order entry for CPOE (i.e., labs, medication, radiology), per Physician/CMSS team across the healthcare enterprise
      9. Customizable full scope of CMSS credential:  Clinical informatics/medical assistive duties, per specialty, per physician

In addition, Certified Medical Scribe Specialists are important in helping patients feel at ease in the physician’s office and often explain certain care instructions, under the supervision of a physician or other healthcare provider.  Certified Medical Scribe Specialists are essential members of a patient-centered medical team

CMS Compliance: “CMS has asked that each clinician/provider/practice retain a copy of the Specialist crosswalk and certification documentation in their files just as they would retain documentation outlining their individual approach and method, as well as staffing protocols for audit purposes.”

Learn more of innovation today:

Become a Certified Medical Scribe Specialist (CMSS) or Certified Medical Scribe Apprentice (CMSA) today; the steps are outlined.

Internal Medicine Study Guide and Exam cover the following basic topics: 

              1. Basic anatomy and function of the human body
              2. Basic diagnosis and treatment of important organ systems:
                1. Heart and Cardiovascular
                2. Lungs
                3. Gastrointestinal
                4. Kidney and Urinary
                5. Central Nervous System
              3. Radiologic studies
              4. Differential diagnosis
              5. Important medications
              6. Disease prevention 

Becoming a Certified Medical Scribe Specialist, or Certified Medical Scribe Apprentice today!

Proceed to our store to start the process.