Sometimes physicians will speak notes about the visit and/or their medical decision making into a dictaphone, scribes will listen to these dictations and translate the information into the EMR.
The scribe will document procedures and treatments performed by healthcare professionals, patient education and explanations of risks and benefits, physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.Also, medical tests that are conducted such as basic vitals or imaging studies will also need to be documented by the medical scribe. During the patient encounter, the patient will answer questions from the physician about symptoms, exercise, diet, which the medical scribe will document.The scribe writes an HPI based on the observed provider and patient interaction. 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 medical scribe will input these records into their system?s Electronic Medical Record (EMR). Each patient will have a unique medical history and an existing medical record.Scribes will assist in the organization of patient information in the electronic medical record (EMR) prior to each patient encounter, allowing providers to move more efficiently between patient visits.Scribes document the entire patient encounter from start to finish including the patient's history, physician exam, provider orders, patient outcomes, labs, imaging and more.Willing to take on additional tasks/work while continuing to manage daily work flow.Be a liasion to the supervisor for any medical scribe issues.Assist supervisor with any and all tasks related to the scribed as needed.Maintains and implements all polices and procedures.Monitor the performance of the department.Oversees and coordinates scribes in the clinical department.The Medical Scribe increases the efficiency and the productivity of the physician they are working for by relieving the physician of the burden of taking the notes and documenting themselves allowing their primary focus to be on the patient. The scribe follows the provider into patient rooms, and serves as the documentor of relevant notes and medical data that traditionally would be recorded by the provider. This unique combination of values, performance standards and commitment serves as the key to our success.The primary responsibility of a medical scribe is documenting and charting medical data discussed during provider-patient encounters. The product of our strict adherence to core values is the ability to harness tremendous organizational energy to achieve our goal of upholding the highest standard for quality and service within the high access healthcare. The expression of these standards is evident in our behavior, our attitude, and our approach to our daily work. Extraordinarily high-performance standards serve as critical guides for making important clinical and business decisions. These essential core values form the foundation of our relationships with patients, customers, investors, partners and one another. With offering services in twelve states (Arizona, Colorado, Kansas, Michigan, Missouri, New Mexico, Nebraska, North Carolina, Oklahoma, Texas, Virginia and Wyoming) and over 155 urgent care clinic locations, we offer exceptional, affordable care to patients across the country.Īt NextCare, we constantly strive to provide you with the highest degree of caring, growth, integrity, results and teamwork. NextCare strives to be the leader in high access healthcare, offering urgent care, occupational health, virtual health and primary care services to our patients.
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