The principal function of a scribe is to facilitate the physician with medical chart documentation. The scribe follows the physician into the patient’s room to record the clinical encounter including patient's history, review of systems, and the physical examination performed by the physician.
Scribes keep track of lab and radiology tests ordered, and then enter the results into the medical chart once completed. Scribes document any consultations the physician makes to a patient's private doctor, specialist, hospitalist or family member.
Scribes document all procedures performed by the physician such as endotracheal intubation, procedural sedation, or laceration repair. Scribes are responsible for documenting the diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient.
Physicians will have time to see more patients, educate residents and nurses, and go home on time. Scribes provide the physician with an extra set of hands, eyes, and ears that will help organize the duties that he/she needs to execute with higher efficiency.
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