Medical Scribe

It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state and federal guidelines for documentation into the electronic medical record. Medical Scribes will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. The Medical Scribe role is not a direct patient care role.

Scribe -Specific Tasks and Duties

• The primary role of the medical scribe is to assist the Clinician with documentation of each patient’s medical chart during his or her visit.
• The scribe accompanies the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
• The scribe, under the direction of the clinician, transcribes patient orders, including laboratory tests, radiology tests, medications, etc.
• The scribe documents any procedures performed by the clinician or nurses, on the electronic medical chart. 
• The scribe transcribes any consultations or discussions with family and/or the clinician.
• The scribe completes the patient’s chart by transcribing results of any labs, x-rays, or other evaluations.  In doing so, the scribe continuously checks on the progress of this data in order to get the patient’s workup complete so that the clinician is able to make his or her decisions regarding that patient.
• The scribe lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
• The scribe does not directly assist with patient care.  The scribe documents orders generated by the clinician.