The central role of the Medical Scribe is to relieve the physician of clerical or secretarial duties; thus allowing the physician to focus more directly on clinical care. The scribe is an unlicensed person and exclusively non-clinical. They do not touch patients and do not engage in any type of patient care. A scribe’s role is limited to documentation and efficiency management for the physician.
The scribe observes the physician during patient encounters and performs documentation on the physician’s behalf. Under the direction of the physician, they enter information into the patient’s electronic or written chart. All documentation is reviewed and edited by the physician. It is signed with an attestation by the provider that the scribed chart accurately reflects all work, treatment, procedures, and medical decision making performed by them.
Scribes function as the physician’s personal secretary and requires access to electronic databases that is similar to the access granted to the physicians themselves. Within the framework of an Electronic Medical Record (EMR) system the scribe needs the functionality to find old records and results. At the physician’s request, the scribe must be able to locate past medical records, prior lab/radiology results, or past visit histories for the physician to review. Additionally, within the EMR itself the scribe needs the ability to enter data into the chart on the physician’s behalf. All scribe-entered data is reviewed and authenticated by the physician.