Medical Scribe
Current- 2000 hours - Document the physician dictated patient history, including the history of present illness, review ofsystems, past medical and surgical history, family and social histories, medications, and allergies- Document physical examination findings and procedures as performed by the physician- document the results of laboratory and radiographic studies as dictated by the physician- Document the correct time of patient care-related activities, including physician to physiciancommunication, family communication, and re-examination of the patient- Make “chart rounds” to review patient status, delays, and any othercare-related issues- Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAAregulations- Demonstrate organizational ability to maintain and coordinate multiple forms and paper documentation related to patient care
