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.
1. Maintain patient confidentiality.
2. Follow the health care provider’s instructions accurately.
3. Make sure all notes are accurate, legible, and complete.
4. Ensure the documentation is compliant with all applicable regulations and laws.
5. Make sure all documentation is completed in a timely manner.
6. Use standard abbreviations and terminology when documenting.
7. Record all vital signs, medications, and treatments accurately and completely.
8. Review all documentation for accuracy before submitting.
9. Ensure that all relevant clinical information is included in the documentation.
10. Monitor the progress of the patient’s care as documented.
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