A scribe handling EHR duties enables a healthcare setting to have shorter door-to-doctor time, better continuity of care, and more meaningful engagement with patients.
Arrive to shift 10 minutes early to prep charts with vital signs, chief complaints, past histories and surgeries, risk factors, and triage notes.
Update Medical Decision Making
Clean up the HPI, ROS, PMSHx, PE, Differential diagnosis’s, and Medical Decision Making.
Our next patient is a complex laceration that will require the attention of my physician for at least 30 minutes. Make comfort rounds to the active 11 patients and communicate with nurses any let patients know the status of labs, medications and note their chief complaints.
Prepare Discharge Education for Patients
Obtain the procedural documentation for the complex laceration and prepare the discharge education for the nursing staff at the physician’s direction. By the time the laceration is complete, this patient is ready for discharge.
Stock Office Supplies Including Printer Paper
By this time I've been tracking labs, radiology, medication administration and we have 6 patients ready for disposition.
Document Conversations with Time Stamp
I present each patient to the physician to make a disposition decision. I've been tracking labs, radiology, medication administration and we have 6 of our patients ready for disposition.
Consult with Physicians for Referral
With the LiveReferral module embedded in the EMR, I check the referred physicians schedule to ensure patient is available to see the doctor in a week.
Walk-in Patient with Missing Finger
Follow the provider into the trauma bay to document a patient with an on-the-job construction site injury. Listen for vitals and document simultaneously in the EMR while care is delivered.
Continue Updating Patient Chart
Detail patient encounter while nurse preps patient for in-patient transfer.