Scribe Programs
Duties An Expectation
- The main responsibility of a scribe is to maintain the electronic health record (EHR) system by entering each patient’s data (medical history and medical record).
- Write the History of present illness (HPI) by observing the patient’s medical record and interactions.
- Recording the patient’s answers given to the physician regarding the diet and exercise as well as the mandatory lab tests and values.
- Transformation or translation of the physician’s dictation from Dictaphones and then recording them into EHR.
- Writing referral or other types of letters for correlation.
- In an emergency department (maintaining medical records, documenting patient discharge information, writing doctor’s excuse notes, composing the prescriptions and then signed by physician). In addition, recording the data that when consultants were called back, re-examination data findings, gathering information from the support staff and providing it to the physician in an emergency department (ED).
- A scribe must also be aware of the issues related to the documentation regarding which symptom or history should be included or excluded from the document.
- While filling a patient chart a scribe must be aware and trained of coding and billing requirements.
- They must write to the point information so that a physician can easily overview the details during their busy shift including filling the procedure, rechecks needed and time needed for critical care.
- A scribe must be aware of the fact that effective patient care is directly related to the good relationship of scribe with other healthcare providers including nurses, pharmacist, paramedics etc.
- Although, scribe is not responsible of direct decision making but working in the shadowing of physician must enable them to understand the logic of medical decisions, terminologies of medical field and other enumerable aspects related to the field.
- While completing a chart he must be able to accurately write the symptoms, lab findings, values, and tests.
- While working on EHR scribe should be able to proficiently arrange the accumulated patient data and should effectively handle the record.
- The other valuable duties of a scribe include reminding the nurses that patient is ready for medication, managing the patients flow and responding the other messages when clinician is busy.
Training and Certification
Training and Certification
