Medical scribe services were introduced originally in the emergency department in the mid-1990s but in the mid-2000s, they began expanding to hospitals, clinics, and urgent care facilities.
The main role of the medical scribe is to record conversations between the physician and patient into the medical record/documentation.
Medical documentation is important for several reasons.
1. The EMR (Electronic Medical record) is the repository where all important information about the patient's medical care is kept.
2.. It serves as a billing tool by which all fees are generated for both the doctor and hospital.
3. The EMR may also serve as a defense against legal claims directed at the doctor and/or hospital.
So for all these reasons, accurate medical documentation is very important.
Maintenance and generation of the EMR can be quite a time consuming and take significant portions of the doctors' time away from patient care. As a scribe, your main job is to take the bulk of this task away from the doctors by producing effective documentation.
Scribes' Goals.
1. Electronic medical record navigation.
2. HIPAA and patient privacy.
3. Flow and function of the ED, hospital, clinic.
4. Basic medical terminology.
5. General anatomy and physiology.
6. Methodology of writing an HPI.
7. Awareness of billing principles as they pertain to the medical notes.
8. Common medications.
