MEDICAL SCRIBING
A medical scribe is a healthcare professional who documents patients and performs clerical tasks on behalf of a physician. Medical scribes now do much of their work in an electronic health record (EHR) system in healthcare facilities that have transitioned from the old paper record system, though some still manually record information in patient charts.
Functions of a Medical Scribe includes :
- Scribes are paired with one physician per shift.
- Scribes accompany the doctor during the patient interview and examination.
- Scribes record the physician-assisted patient history, which includes the patient's current illness, a review of systems, previous medical and surgical history, family and social histories, medications, and allergies.
- Scribes record physical examination findings and procedures as they are performed by the doctor.
- Scribes record the results of laboratory and radiographic studies as ordered by the doctor.
- Scribes record the correct time of patient care-related activities such as physician-to-physician communication, family communication, and patient re-examination.
- At the end of the patient's visit, the physician will review all documentation completed by the Scribe, make any necessary changes, and sign the chart.
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