MEDICAL SCRIBING
Medical Scribe is an assistant to the doctor who is responsible for recording patient's medical histories or any information dictated to them.
ESSENTIAL DUTY AND RESPONSIBILITIES:
- Accompany the doctor while they interview and examine the patient in the exam room.
- Welcome clients and guests with a warm grin.
- Enter the patient's history as it was given by the doctor into the electronic health record (EHR), including details on the patient's current disease, a review of the systems, prior procedures, family and social histories, medical history, and allergies.
- Record the physician's actions during the physical examination, including any findings.
- When directed by the doctor, record the outcomes of laboratory and radiographic studies.
- Participate in the collaborative effort between the doctor, nurse, administrative assistant, and scribe.
- When documenting, exercise discretion, sensitivity, and modesty to avoid upsetting the doctor or the patient.
- Help other departments as required.
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