MEDICAL SCRIBING
A medical scribe is an allied health worker who documents doctor-patient interactions as they occur, such as during physical exams. They also locate data and patients for doctors and complete the documentation required for patient care.
A Medical Scribe's Responsibilities:
- The major responsibility of a scribe is to enter each patient's data into the electronic health record (EHR) system, which must be kept current (medical history and medical record).
- Write the History of Present Illness (HPI) after researching the patient's medical history and interactions.
- Keeping a record of the patient's responses to the doctor's questions regarding their food, activities, and required lab tests and findings.
- Before recording the doctor's dictation from Dictaphones in the electronic health record, it is transformed or translated.
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