MEDICAL SCRIBING
A medical scribe is a doctor's assistant who records the patient's family and medical histories, treatments, allergies, lab results, and any other information that the doctor dictates to them or that is pertinent to the patient's visit.
- A scribe's primary duty is to enter each patient's data into the electronic health record (EHR) system, which must be kept up to date (medical history and medical record).
- By studying the patient's medical history and interactions, write the History of Present Illness (HPI).
- keeping a record of the patient's responses to the doctor's questions about their food, activity, and the required lab tests and results.
- Transforming or translating the doctor's dictation from dictaphones before recording it in the electronic health record.
- Creating recommendation or other kinds of correspondence for correlation.
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