The medical industry is increasingly focused on patient-centered care. A fact reflected in increasing demands of practice for corporate compliance, new healthcare models, new coding and documentation requirements and ever changing revenue cycles. Scribes help medical facilities stay ahead of the curve in this regard, as scribes free physicians from time-consuming documentation responsibilities.
Scribes assist by recording the patient visit in real time. They increase time-spent with patients and minimize time used to write medical notes.
The goal of the scribe is to have all the relevant information recorded into the EMR, so that by the end of the visit the provider only needs to proof the note and dictate the assessment and plan before closing the note and moving onto the next patient.
Scribes are responsible for recording and updating the following; :
- History of the Patient’s Current Illness
- Review-Of-Systems (ROS) and Physical Examinations
- Vital Signs and Lab Values
- Recording Results of Imaging Studies
- Continued Care Plans and Updating Medication Lists
- Past, Family and Social History
- Updating Problem Lists
- Medication Reconciliation
- Prepare Lab Orders and Diagnostic Testing
- CPT and ICD-9 Diagnosis Coding Requirements
- Meaningful Use (i.e. Patient portals for email communications)