The primary role of the Medical Scribe is to relieve the practitioner of clerical and secretarial duties; thus allowing the practitioner to focus more directly on clinical care. The scribe is an unlicensed individual and exclusively non-clinical. They do not examine patients and do not engage in any type of patient care. A scribe’s role is limited to documentation and efficiency management for the practitioner. Must be able to travel to our satellite offices (except Yuma).
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
- Assists the practitioner in navigating the Electronic Health Record (EHR) and may locate information for review as requested by the practitioner (i.e., previous notes, reports, test results, and laboratory results). Also, may research information requested by the practitioner.
- Accompanies the practitioner upon patient interview and examination and they do not interject their own observations or impressions.
- Documents the practitioner dictated patient history, including history of present illness; review of systems; past medical and surgical history; family and social histories; and medications and allergies.
- Documents physical examination findings and procedures as performed by the practitioner.
- Documents the results of laboratory and radiographic studies as dictated by the practitioner.
- Documents the correct time of patient care related activities, including practitioner to practitioner communication, family communication and re-examination of the patient.
- Ensures the practitioner reviews all documentation completed by the Scribe when the patient encounter has concluded. This includes making any necessary amendments and signing the chart. The practitioner is ultimately responsible for documentation of the patient’s encounter.
- Make “chart rounds” with the practitioner to review patient status, delays, and any other care-related issues.
- Ensures authentication takes place before the Practitioner and scribe leave the patient care area and that all orders for patient care are communicated by the practitioner.
- Performs miscellaneous job related duties as requested.