The primary responsibility of a Medical Assistant/Medical Scribe is documenting and charting medical data discussed during provider-patient encounters. The scribe follows the provider into patient rooms, and serves as the documenter of relevant notes and medical data that traditionally would be recorded by the provider.
- Place patients in the examination rooms and document for physician the medications, vitals and main reason for the visit.
- Record Vital Signs including height, weight, blood pressure, pulse & temperature.
- Enter patient information into the Electronic Medical Record.
- Assist the physician with special procedures and examinations as needed.
- Collect blood or other laboratory specimens as requested by the physician.
- Perform routine laboratory tests and EKGs.
- Obtain previous test results from outside labs, radiology, doctor’s offices, etc.
- Explain treatment procedures, medications, diets and physicians instructions to patient in a clear and effective manner.
- Clean and sterilize instruments and dispose of contaminated supplies.
- Maintain an adequate inventory of medical supplies in each exam room.
- Ensure the cleanliness of each exam room. Prep rooms after each patient and for specific procedures as needed.
- Order medical supplies as needed.
- Ensure HIPAA guidelines are followed at all times.
- History of Present Illness (HPI) is a concise narrative of the patient’s story that includes the context of their chief complaint, past medical history, symptoms, that the medical scribe is creating. The scribe writes an HPI based on the observed provider and patient interaction.
- Perform administrative duties when needed: answering phones, scheduling appointments.
- Write referral letters for doctors or other types of correspondence.
- Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. Any changes or corrections must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.
- Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.