What is a Medical Scribe?

A medical scribe is a professional who specializes in documenting patient encounters in real-time during medical examinations. They work closely with healthcare providers, such as physicians, nurses, and physician assistants, to capture and record the details of patient visits. Medical scribes are responsible for entering information into electronic health records (EHRs) or other documentation systems, allowing healthcare providers to focus more on patient care. By handling the administrative aspects of documentation, scribes help to streamline the clinical workflow and enhance the efficiency of medical practices.

The primary duties of a medical scribe include:

  1. Documentation: They listen to the interactions between the healthcare provider and the patient and transcribe the details of the visit into the patient’s medical record. This includes documenting the history of present illness, physical examination findings, diagnoses, treatment plans, and follow-up instructions.
  2. EHR Management: Medical scribes are adept at navigating electronic health record systems. They enter data into the EHR in real-time, ensuring that all information is up-to-date and accurately reflects the patient encounter.
  3. Order Entry: Scribes may assist in entering orders for laboratory tests, imaging studies, medications, and referrals as directed by the healthcare provider.
  4. Chart Review: They review patient charts and histories to gather information needed for the visit, helping the healthcare provider to stay informed and prepared.
  5. Workflow Efficiency: Medical scribes play a key role in optimizing the clinical workflow. They help reduce the administrative burden on healthcare providers, allowing them to see more patients and focus on providing high-quality care.