MEDICAL SCRIBING
A medical scribe is an assistant to the physician who is responsible for documenting patients' family and medical histories, treatments, allergies, lab results and any information dictated to them or relevant to the patient's visit.
1. Documenting the patient's medical history, including their chief complaint, medical history, current medications, allergies, and any pertinent family history.
2. Accurately recording the patient’s physical examination findings and vitals.
3. Transcribing the provider’s orders and follow-up instructions.
4. Generating patient charts, including review of systems and past medical history.
5. Creating treatment and progress notes.
6. Ensuring that all documents are complete and accurate.
7. Maintaining patient confidentiality and HIPAA compliance.
8. Assisting the physician with any additional tasks as needed.
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