A Medical Scribe is a revolutionary concept in modern medicine. Traditionally, a physician's job has focused solely on direct patient contact and care. However, the advent of the Electronic Health Record (EHR) created an overload of documentation and clerical responsibilities that slows physicians down and pulls them away from actual patient care. To relieve the documentation overload, physicians across the country are turning to Medical Scribe services.
A Medical Scribe is essentially a personal assistant to the physician; performing documentation in the EHR, gathering information for the patient's visit, and partnering with the physician to deliver the pinnacle of efficient patient care.
For someone interested in medicine, whether it is a personal interest, or part of a career goal to become a physician or physician assistant, the chance to become a Medical Scribe is unlike any other opportunity available. It offers exciting one-on-one collaboration with a physician, and is unprecedented in its level of exposure to real medicine in practice.
A Medical Scribing Specialist is a personal assistant to the physician, performing among many tasks, electronic record keeping responsibilities for the physicians during patient encounters.
This includes gathering information for the patient’s visit, performing documentation directly into the EHR in real-time, querying and using the EHR to manage the patient’s progress.
An MS partners with the physician to ensure the best patient care.
Working as an MS is a truly rewarding experience. This is a front-line service where you are actively involved with the physician to deliver optimal healthcare to patients.
Dealing with experienced American physicians will build confidence in your work and promises a unique learning experience. Working closely with a physician will allow you to personalize the service you give to the physician.
The purpose of this position is to handle medical data documentation responsibilities for physicians during patient encounters.
Medical Assistant access live doctor-patient interactions remotely and accurately document the events and decision-making in a manner that results in appropriate medical charting.
By accomplishing the time-consuming clerical duties that would otherwise be assigned to a physician, scribes enable physicians to spend more time with individual patients and increase the overall flow of patients in the department.
The primary responsibilities for this position include but are not limited to:
Accurate and timely charting of patient encounters, including but not limited to patient history, physical exam, diagnostic findings, lab and test results, Medical decision making etc.
Interact with the physician in a professional and non-intrusive way to ensure completeness and accuracy in medical charting.
Compliance with HIPAA, HITECH, and policies relating to confidentiality of patient information.
Excellent job attendance.
Other duties as assigned, including but not limited to training other Medical assistants and staff.
A Medical Scribing Specialist (MS) also sometimes referred to as Medical Scribe or Scribe is the “Right hand person” to a provider and partners with him/her to deliver the zenith of Medical Care to patients.
A virtual Medical Scribe or Medical Scribing Specialist seated anywhere in the world in a HIPAA secure location is connected to his/her physician or doctor via cutting-edge technology that provides access to the doctor’s office. This wearable technology allows the Medical Scribing Specialist (MS) to shadow the provider and create medical documents in real time directly into the EH-R / Electronic Health Record after reviewing the same with the provider. HIPAA (Health Insurance Portability and Accountability Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.
To define a Medical Scribing Specialist’s typical day as busy and intense is a bit of an understatement given the multitude of high-value activities a Medical Scribing Specialist performs to deliver an experience primarily to the provider and generally to the US healthcare system. The job of a Medical Scribing Specialist is as reenergizing and fulfilling, as it is intense and tiring.
A Medical Scribing Specialist gets to his HIPAA secure office about an hour earlier to his provider’s scheduled start time. The office is a secure fortress with a combination of physical and electronic security apparatus to ensure PHI/e-PHI is protected and only authorized personnel are allowed access to the facility. PHI stands for Protected health information.
The Medical Scribing Specialist enters the office space after a systematic security screening process. The scribe production areas are essentially quarantined from anything that is considered a threat to PHI (Protected health information) leak. Writing material, electronic gadgets, etc. are deposited in secure lockers before the scribe enters the production area.
The Medical Scribing Specialist uses a personalized Yubikey to log in and access the Scribe Cock-pit and electronically register his attendance into the shift-planning calendar. He goes on to check his official e-mails for any updates related to his provider’s schedule. Pre-charting for current day’s and future visits are undertaken as part of his preparation for the doctor’s shift. Prep times are dependent on the number of patients scheduled. The Medical Scribing Specialist normally logs into stream 15 minutes ahead of the provider’s scheduled start-time. He makes note of QA feedbacks if any. In an unlikely event that the doctor is not available on stream due to a technical glitch, the scribe immediately communicates to frontline support and our internal tech support. The cause of the glitch could range from a simple “doctor forgets to switch on Google Glass” and “Wi-Fi disruptions” to the more serious “all ISPs going down.” Zendesk tickets are raised, and the issue is flagged for resolution at various levels depending on the seriousness of the problem. The doctor’s office is kept informed of the situation as well.
The Medical Scribe starts his shift wishing his doctor and sometimes even manages to sneak in a couple of minutes of friendly banter. A Medical Scribing Specialist as a matter of practice checks the Google Glass battery charge and alerts the doctor in cases where the battery charge is below the threshold. The Medical Scribing Specialist goes on to take notes based on the doctor-patient interactions and the visuals that is available from Google Glass into the note-writer available in the cockpit and transfers the same into the EH-R, all this in real-time. While the primary responsibility of the Medical Scribing Specialist is to ensure all the doctor patient interactions are documented, the scribe also performs other duties such as alerting the doctor on patient appointments, accessing relevant patient information from previous records and making them available, checking for inconsistent documentation and documentation deficiencies, assisting the provider in finding the relevant medical codes, printing PT forms, lab results, and AVS forms for the patient.
The Medical Scribing Specialist (MS) maintains a friendly but professional relationship with his doctor to work alongside the doctor/physician and ensure a fruitful association. Providers spend time with their scribes in educating them and sometimes sharing personal experiences. In cases where the scribe has missed out on information due to technical and/or other issues, the scribe has the discretion of checking with a doctor with a specific question that he/she needs clarification on. Doctors are more than willing to help their scribes which in turn helps their productivity.
The medical scribe manages his shift based on his provider’s schedule. He tailors his breaks and harmonizes the same with the medical doctor’s schedule to optimize provider productivity. For e.g., the scribe takes his dinner break when the doctor leaves for lunch. Scribes are trained to be respectful and polite in the most difficult situations. They sometimes are required to say “no” in a manner that would not offend their provider. Scribes complete all their charting with the specified shift hours and complete EOD summaries before they sign-off. Time permitting, a quick chat before end-of-shift with their provider is normal practice. Yubikeys are deposited in predefined secure lockers before the scribe heads homewards for a restful day to recuperate and prepare for another eventful shift.
Tony Hales, CEO OnlyGroup Healthcare