Medical Sribing In Trivandrum

 MEDICAL SCRIBING

A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe (in the emergency department), or just scribe. A scribe is trained in health information management and the use of health information management and the use of health information technology to support it. A scribe can work on-site or remotely from a HIPAA-secure facility. Medical scribes who work at an off-site location are known as virtual medical scribe.

The main responsibility of a scribe is to maintain the electronic health record (EHR) system by entering each patient's data. Write the History of present illness (HPI) by observing the patient's medical record and interactions. Recording the patient's answers given to the physician regarding the diet and exercise as well as mandatory lab tests and values. Transformation or translation of the physician's dictation from Dictaphones and then recording them into EHR. Writing referral or other types of letters for correlation. A scribe must also be aware of the issues related to the documentation regarding which symptoms or history should be included or excluded from the document.

While filling a patient chart a scribe must be aware and trained of coding and billing requirements.They must write to the point information so that a physician can easily overview the details during their busy shift including filling the procedure , rechecks needed and time needed for critical care .A scribe must be aware of the fact that effective patient care is directly related to good relationship of scribe with other healthcare providers including nurses,pharmacist, paramedics etc. Although, scribe is not responsible of direct  decisions, terminologies of medical field and other enumerable aspects related to the field.The other valuable duties of a scribe include reminding the nurses that patient is ready for medication managing the patient flow and responding the other message when clinician is busy.