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.