Scribe

A scribe is a documentation assistant recording in real time the facts and events that occur between a patient and a physician or other provider during a patient encounter. The scribe accompanies the provider to the treatment area and records in the electronic or paper medical record the results of the history and physical as they are verbalized by the examining provider and the patient. The scribes role is to facilitate patient flow through the Emergency Department and ensure an accurate and complete medical record for each patient. The duties of a Scribe are to document the physician dictated patient history physical examination family social and past medical history as well as document procedures lab results dictated radiographic impressions made by the provider and any other information pertaining to the patients encounter in the Emergency Department.

Essential functions performed:
1. Scribes accompany the provider upon patient interview and examination.
2. Scribes document the provider dictated patient history including history of present illness review of systems past medical and surgical history family and social histories medications and allergies.
3. Scribes document physical examination findings and procedures as performed by the provider.
4. Scribes document the results of laboratory and radiographic studies as dictated by the provider.
5. Scribes document the correct time of patient care related activities including provider to provider communication family communication and reexamination of the patient.
6. When the provider concludes the patients encounter the provider will review all documentation completed by the scribe make any necessary amendments and sign the chart. The provider is ultimately responsible for documentation of the patients encounter.
7. All orders for patient care must be communicated by the provider and not the scribe.

The ED Scribe performs all clerical and information technology functions for ED physicians or midlevel providers including primary responsibility for the operation of electronic health records and electronic dictation systems. The scribe will be under direct oversight of the emergency department physician or advance practice provider (NP/PA). The Emergency Department provider will review and approve actions to be taken at key junctures during patient care.

High School diploma or GED.
Two years of undergraduate education with an emphasis in premedical studies or Nursing.
Knowledge of medical terminology. Recognition of the physical exam process and ability to record exam details. Demonstrates the knowledge and skills necessary to document patient care as dictated by the provider in a legible and clear manner following all local state and federal guidelines for documentation. Maintains and demonstrates an understanding of the team approach to patient care and documentation. Completes and presents the medical record in collaboration with the supervising physician. Computer and typing proficiency and ability to quickly learn new applications. Organizational skills with focus on tracking patient care and improving patient flow. Professional demeanor and recognition of privacy considerations for patients and families. Ability to multitask. Consistently communicates in a professional manner. Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job. Ability to spell proofread and edit written text. Strong attention to detail. Ability to work in a dynamic highlystressful environment that routinely involves exposure to highlysensitive personal medical issues. Ability to coordinate multiple projects and patients. Punctuality and preparedness for all shifts and workrelated activities.None