When the physician concludes the patient's encounter, the physician will review all documentation completed by the scribe. Scribes document physical examination findings and procedures as performed by the physician.Ī scribe will document the results of laboratory and radiographic studies as dictated by the physician.Ī scribe will document the correct time of patient care-related activities, including physician-to-physician communication, family communication and re-examination of a patient.Ī scribe will not sign patient encounters. The essential functions of a scribe are that:Ī scribe will accompany the physician upon patient interview and examination.Ī scribe will accurately and thoroughly document the physician-dictated patient history, including history of present illness, review of systems, past medical and surgical history, family and social histories, medications and allergies. Must be able to withstand the physical demands of the position, which include, but are not limited to, standing for long periods of time, long periods of computer screen time and carrying a laptop or pushing a workstation on wheels. Must have good judgement, organizational skills, initiative, attention to detail, be adaptable and versatile. Self-motivation and mutitasking are especially important when working as a medical scribe.
OCALA ER SCRIBE PROFESSIONAL
Medical scribes must be discreet and professional in performing their duties as to not distract any medical personnel from patient care. Documentation will also include procedures, lab results, dictated radiographic impressions made by the supervising physician and any other information pertaining to the patient's encounter. The position is responsible for documenting the physician-dictated patient history, physical examination, family, social and past medical history.
This position serves as a representative of the physician.
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