MEDICAL SCRIBING
A medical scribe is someone who follows a doctor and documents real-life exchanges between a doctor and a patient in an EHR (electronic health record). They also search information and patients for doctors, as well as fill out papers required for patient treatment.
An EHR is an electronic version of a patient's medical history that is maintained by the provider over time and may include all of the key administrative clinical data relevant to that person's care under a specific provider, such as progress notes, problems, medication, vital signs, past medical history, and radiology reports. The EHR can also support other care-related tasks, either directly or indirectly, through various interventions such as evidence-based decision support, quality monitoring, and outcomes reporting.
A medical scribe's primary responsibilities include:
- Charting patient contacts accurately and on time, including but not limited to patient history, physical exam, diagnostic findings, lab and test results, medical decision making, and so on.
- Interact professionally and non-intrusively with the physician to ensure completeness and accuracy in medical documentation.
- Other responsibilities include, but are not limited to, training other medical assistants and personnel.
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