Job

Outpatient Scribe Job Description

It is important to note Texas law allows young people at age 15 (except for special occasions on a judges orders) to work in the hospital setting as a volunteer with no more pay than $600 a year.  Other laws like a permit to drive at that age are also allowed through the USA court systems.  I started out as a candy striper in a Abilene Texas hospital's gift shop as a volunteer.

As an outpatient scribe you will work one-on-one with physicians functioning as their personal assistant. The scribe’s role is to increase outpatient practice efficiency by lessening the physician’s burden of documentation and organizational responsibility. By directly assisting the physician with all non-clinical tasks the scribe allows for greater physician-patient care and increased physician efficiency. This job is exclusively clerical and does not allow for any physical patient contact or medical care; however, it is second-to-none for direct exposure to outpatient medicine, disease processes, medical decision making, and medical procedures. Because you are working alongside physicians, the potential to gain knowledge is virtually limitless, dependent only on your motivation to learn. Though the work is intense the experience is rewarding and full of excitement.  This includes shift-to-value.  That term is used for preventative medicine council for patients, and when properly documented most doctors will received a bonus.

 

When your physician arrives to the clinic you begin to see patients with the physician, based on the scheduled appointments for the day. As a scribe, you enter the patient’s room with the physician and record notes as the doctor asks the patient questions. The physician then performs the physical examination and verbalizes the findings to you at bedside. You will document the assessment and plan as dictated by the physician and get the patient’s chart ready for check-out. By allowing the doctor to simultaneously complete patient care and documentation you greatly increase the efficiency of the clinic. Additionally, physicians appreciate the time that is liberated from documentation, allowing them to perform fewer clerical tasks and more of the medical practices they enjoy. Your day as a scribe is also filled with miscellaneous tasks that include looking up old medical records, old radiology studies, placing phone calls, or transcribing special instructions from the physician. The work environment is fast-paced and bustling and there is always new work to be done. The work of a scribe is indeed strenuous; however, the variety of experiences, direct exposure to medicine, and unique excitement make this job one-of-a-kind.

GENERAL:

A “SCRIBE” is an ancillary outpatient staff member that creates a dynamic conduit between a tangible

document and the patient encounter, clinical exam and provided care. The role is exclusively clerical;

the SCRIBE does not autonomously author any medical information. The only type of information

transfer afforded to a SCRIBE consists of discrete material upon which the SCRIBE has no influence or

effect. SCRIBEs function in an auxiliary information pathway to afford the physician or mid-level

provider (collectively, “the provider”) with real time access to substantive documentation without

compromising normal routes of facility communication or efficiency. This role is relevant because

providers are highly trained for direct patient care and any clerical activity is a less efficient use of their

health care expertise and efforts.

IN REGARDS TO DOCUMENTATION:

With the Electronic Medical Record (EMR) or paper documentation system, the SCRIBE records

procedures, results, progress notes, and any additional information relevant to the chart. Notes

can include the provider’s verbalized interaction with patients, physical exam findings, medical

assessment, laboratory results, radiological reports, consultations, and plans. Additionally the

SCRIBE may provide detailed accounts of clinical proceedings including time-stamped events and

procedural notes.

The SCRIBE may assist the provider in entering the clinical impression, discharge instructions,

computerized physician order entry (CPOE), and completion of the superbill. All information

related to the History of Present Illness (HPI), Physical Examination (PE) and Medical Decision

making is specifically obtained and/or performed by the provider while the SCRIBE’s role is a

recording function only.

As an ancillary staff member, depending on the facility, the SCRIBE may independently gather and

document clinical information that is read from a standardized facility-approved template

regarding the review of systems (ROS), or past family and social history (PFSH). In an outpatient

setting the SCRIBE is able to personally obtain PFSH directly from the patient prior to the provider

entering the patient room to complete the visit. All information obtained by the SCRIBE regarding

the ROS or PFSH is reviewed by the provider and verified for accuracy. In addition, the SCRIBE may

obtain a patient’s old medical records and previous studies.

The SCRIBE does not interject his or her own opinions or impressions, and does not interpret

clinical information. The SCRIBE serves in a strictly clerical role that does not involve physical

patient contact at any time.

A SCRIBE’s unique login and password may also allow access to CPOE only if permitted by the

facility, as long as the facility is not trying to meet Meaningful Use stage 1 or 2 criteria.

The SCRIBE’s note must also include:

The name of the SCRIBE and a legible signature or electronic stamp and attestation.

The name of the provider caring for the patient.

The name of the patient for whom the service was provided.

The provider’s note must indicate:

Affirmation of the provider’s presence during the patient encounter.

Verification that the provider reviewed the chart.

Verification of the accuracy of all information.

IN REGARDS TO EFFICIENCY MANAGEMENT:

The following is a list of duties and activities that SCRIBEs are trained and competent to perform in

support of the provider’s time management:

Real-Time Documentation: The SCRIBE documents the history, physical, and patient course as

described above.

Communication: Examples may include answering telephones, scanning document into the

Electronic Medical Record, and assisting the physician with printing information from the chart as

needed for admission and communication with other health care providers.

Testing Collation: Locating diagnostic information, including laboratory and radiographic results,

or recording the interpretation of the provider.

Focused Health Record Compilation: Locating and organizing disparate parts of each patient’s

medical record including past medical records from the EMR systems as well as written charts and

past diagnostic studies, when needed.

Advocacy: Acting as a patient advocate by communicating the patient’s needs and requests to the

appropriate provider.

Notification: Notifying the provider when relevant patient information is available.

Privacy: Depending on the facility, SCRIBES may serve as a chaperone for sensitive portions of the

medical history and physical exam.

Boundary Management: SCRIBEs never physically touch patients or assist in procedures.

Mindset:

These include commitment, talent in multitasking, critical thinking, adaptability, organization, excellent communication skills, unwavering work ethic, reliability, and a persisting desire to excel. Not only are these attributes necessary to succeed in outpatient medicine but our training regime is too rigorous to be completed without them.

 

Source: ScribeAmerica

Tier or Rank system
CEO President
Vice President
Director
Chief Scribe
Quality Assurance Scribe/Trainer
Medical Scribe
(I will update this as soon as I figure it out)