Medical Scribing Medical Scribe A personal assistant to a licensed healthcare provider. A medical scribe specializes in documenting patient encounters in electronic health/medical records (EHR/EMR). Roles and Duties Typical Flow Real-time documentation of patient-provider encounters Documenting dictations from providers outside of the patient room if necessary Retrieving previous records including laboratory and radiology results Capable of typing notes at a fast enough rate that will not deprive the provider of reaping the benefits of having a medical scribe Understand commonly used medical abbreviation and medical terminology Understand additional commonly used medical abbreviations and medical terminology that pertains to the specialty of which you are working Capable of paying attention to detail Work unnoticeably and in a manner not disruptive to quality patient care Document procedures that are performed by the provider Provide continuous assistance to quality care in and out of the patient examination rooms Chart review: The medical scribe and the provider together reviews prior records, labs/radiology results, and nursing/medical assistant triage note. HPI: As the provider speaks with the patient, the history of the problem is documented by the medical scribe. Physical Examination: As the provider exams the patient, the medical scribe will document their examination in the EHR. Laboratory and Radiology: The medical scribe records the results of lab work and imaging dictated by the provider. Assessment: The medical scribe documents the provider's diagnosis and assigns the appropriate ICD-10 codes. Treatment and Medical Decision Making: The medical scribe documents all discussions, recommendations, procedures, and plans that correlates with the patient's treatment. Interested in Acquiring a Medical Scribe?Visit our scribe priming solution catalog to find the perfect program for you! Interested in Becoming a Medical Scribe?Get started today by registering for our free scribe mini course! Program Catalog! Register Now!