The scribe would be responsible for managing US physicians documentation on the electronic platform. The scribe would listen to the physician patient interaction and is expected to summarize the same in the electronic health record. This summarized note should reflect patients problem and physicians plan around the same. The chart note generated by the scribe would be used by the physician as a reference document.
Main role of the scribe is to create medicolegally compliant, clinically sound high quality outpatient visit documentation for some of the best US Hospitals across multiple specialties
1. Listen and comprehend recorded patient physician interactions, develop an impression about the clinical condition and document clinical history, examination findings & plan of action
2. Create highly structured (literally medical text-book style) clinical notes, summarize findings and insights with sections such as history of present illness, review of systems, physical examination, assessment details, treatment plan etc.
3. Populate the summarized data in the electronic health record.(EHR)
4. Maintain clinical note quality using documentation norms and physician preferences
5. Understand and maintain desired level of clinical knowledge based on assigned specialty
6. Review edits made by the provider before approving the clinical note and work collaboratively with training and quality to improve the provider experience
7. Share best practices and help create a knowledge repository to capture tacit knowledge