MEDICAL SCRIBING COURSE

 MEDICAL SCRIBE

A medical scribe is a paraprofessional trained in health information management and the use of health information technology. Their responsibility is to enter patient information into the EHR in real-time during medical exams. Medical scribes allow physicians to focus on direct patient care by managing the non-clinical, clerical tasks of documentation and transcription.Generally, medical scribes work on-site at one particular hospital or clinic, though they can also work remotely from a HIPAA-secure location. At their assigned facility, they usually partner with several providers and are assigned to physicians on an as-needed basis.The primary duty of a medical scribe is to record the details of a patient’s exam—clinical history, current complaints, diagnoses, procedures performed (either by the physician or other healthcare professionals) and medical orders given (including prescriptions and tests). Scribes may also be present to document the physician’s conversations with family members or consultations with other healthcare providers.

Scribes may enter post-exam data into the EHR, including the results of X-rays, MRIs and other lab work so the physician has all of the necessary data to make treatment decisions.

A Medical Scribe Specialist is essentially a real-time personal assistant to the physician, performing documentation in the Electronic Health Record system, gathering information for the patient’s visit, and partnering with the physician to deliver the pinnacle of efficient patient care and electronic payment processing.

Many physicians report that working with medical scribes—who assist with administrative tasks during patient visits, such as by entering information into EHRs—enables them to spend more of their time caring for more patients.

Little research exists, however, on whether employing scribes leads to a large enough boost to physician productivity to save hospitals money on the whole, or how the presence of scribes affects patient safety.

To help close the research gap, Katherine Walker, director of emergency medicine research for Cabrini Hospital, and her colleagues randomly assigned medical scribes to 88 doctors in five EDs in Australia between November 2016 and January 2018. The study was the first multicenter, randomized study to evaluate scribes’ impact on physician productivity or patient safety incidents.

As a scribe, I was responsible for taking notes during a patient interview, writing up the encounter on a medical chart, and assisting with the flow of patients through the emergency department.

On a given day, I was scheduled to work with a single health care provider for the entire shift. After taking notes from the patient interview, if time permitted, I would enter the history of present illness (HPI), review of systems, and document physician dictated notes such as the physical exam, differential diagnoses, and progress notes.

There were also a number of small duties to manage at various times throughout the visit, such as calling consults and obtaining medical records from other facilities. The ultimate goal is to improve physician productivity by allowing them to focus on the medical decision making, thereby improving patient flow and overall outcomes.

A Medical Scribe is a revolutionary concept in modern medicine. Traditionally, a physician's job has focused solely on direct patient contact and care. However, the advent of the Electronic Health Record (EHR) created an overload of documentation and clerical responsibilities that slows physicians down and pulls them away from actual patient care. To relieve the documentation overload, physicians across the country are turning to Medical Scribe services.

A Medical Scribe is essentially a personal assistant to the physician; performing documentation in the EHR, gathering information for the patient's visit, and partnering with the physician to deliver the pinnacle of efficient patient care.

For someone interested in medicine, whether it is a personal interest, or part of a career goal to become a physician or physician assistant, the chance to become a Medical Scribe is unlike any other opportunity available. It offers exciting one-on-one collaboration with a physician, and is unprecedented in its level of exposure to real medicine in practice.

A medical scribe is an assistant to the physician who is responsible for documenting patients' family and medical histories, treatments, allergies, lab results and any information dictated to them or relevant to the patient's visit. Because they are knowledgeable about medical terminologies and have some clinical experience, a medical scribe often writes as a doctor would, being sure to check for any errors. In case of any inconsistencies, they inform the doctors, help resolve the issue and even complete records. However, they are not responsible for deciding the patient's treatment or their care.

The scribe records all information electronically, and their work is accessible to doctors who need to check the patient's medical track. Managers, often a nurse or a quality assurance specialist, monitor the work of medical scribes. By recording every event and treatment procedure, scribes allow doctors to concentrate on their patients while taking care of their clerical duties. By performing their work well, a medical scribe helps improve the efficiency of the doctor-patient interaction and ensures the accuracy of important health records.