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MEDICAL SCRIBING 



                     A medical scribe is an allied health worker that focuses on documenting doctor-patient interactions in real time, including during physical exams. Along with finding data and patients for doctors, they also fill out forms required for patient treatment. The job title may also be referred to as clinical scribe, ER scribe, ED scribe, or plain scribe, depending on the specialty the scribe practises in (when the context is implicit). A scribe is educated in the management of health information and the use of health information technology to it. In a HIPAA-secure location, a scribe can work remotely or on-site (in a hospital or clinic).

COMMON DUTIES OF A MEDICAL SCRIBE

  • Collect correct patient information and complete full medical histories in the electronic health record (EHR).
  •  Enter doctor's orders into the EHR.
  • Keep a record of the patient visit's vitals, primary complaint, evaluation, treatment plan, and procedure notes.
  • Help with check-in and check-out procedures for patients, including making follow-up appointments.
  • Uphold patient privacy in compliance with HIPAA guidelines.
  • Support medical professionals in operations, diagnostic tests, and patient care.
  • Keep an eye on the flow of patients and let doctors know when patients are prepared for their visits.
  • Get patient records ready for a doctor's review.
  • Compile and arrange test results and medical records.
  • Update the EHR with new patient data.

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