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Medical Scribes

The Job

The primary function of a medical scribe is to record all aspects of doctor/patient interaction and information significant to the treatment of a patient. To do so, the medical scribe will ordinarily accompany the physician (or other medical provider) during patient interviews, examinations, tests or procedures. As information is elicited by the physician from the patient, or being provided to the patient by the physician, the medical scribe will record and document the communications.

The position of medical scribe may sometimes be assigned to a “virtual” medical scribe, who serves a similar function, but is not physically present in the room, but  gathers information by microphone or observing electronically. In either event, having a medical scribe enables doctors to focus more on patient care, and less on data entry. Given the current requirements for electronic health and medical records, the medical scribe will most often record information electronically, directly to a computer, using software specifically designed for such purpose.

Such electronic record will contain a patient’s medical and social history, prescriptions and allergies, as well as the doctor’s examination and procedures, advice and recommendations. Often the medical scribe will be responsible to compile information from the exam, doctor’s orders, tests and lab results, prescriptions and other significant data into the patient’s electronic medical record to assure that it is complete and accurate.

The medical scribe may record the time spent by the physician in exams, and “code” data, which consists of translating medical information such as diagnosis of injury or illness into a designated format using assigned numerical codes.

 The records created by a medical scribe are critical not only to create an up-to-date patient medical record for treatment purposes but also for billing and insurance claims and to protect physicians in the event of malpractice claims. The scribe’s information is always passed on to the physician for review and approval.

 

 

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