Scribe

A Scribe is a staff member who accompanies a provider into the room and documents what they see, hear and observe. A scribe may not add anything to the documentation and may not perform any of the work of the encounter, outside of the subjective portion as relayed by the patient and dictated as given by the provider according to the 2021 Documentation Guidelines.

A scribe is entrusted with great responsibility to accurately and thoroughly document the entire patient visit which includes history of present illness, current and past medical history, examination, imaging studies, assessment, medical decision making, patient education and explanation of risks and benefits.

Collection of intake to include current medications, allergies, past medical history, social history, surgical history and family history, at the intake desk or in the patient’s exam room prior to being seen by the physician. All intake information, to include anything pertaining to history of present illness, obtained must be reviewed and confirmed by the physician.

Scribes are responsible for ensuring notes are prepped the day ahead of the physician’s schedule which can include data from a previous note; i.e., HPI, imaging reports and treatment recommendations given by the physician to date. A note can only be prepped with historical data that was obtained by a provider for the presenting problem.

A scribe will accompany the physician into the patient’s exam room to transcribe the progress note live time and as directed by the physician. Under no circumstance should a scribe act independently when prepping or documenting notes live time.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to type fast and must comply with HIPAA confidentiality standards
• Responsible for ensuring notes are prepped the day prior to clinic
• Accurately and thoroughly document patient-physician encounters
• Maintain constant communication with the physician
• Provide technical assistance to the physician in the room; i.e., imaging, previous records
• Maintain patient confidentiality in compliance with company policies and procedures