Medical Scribe/Transcription Presentation.pptx

Medical Scribing

1. WFM TECHNOLOGIES The Role of Medical Scribing Enhancing Efficiency in Healthcare

2. A medical scribe -- also known as a Clinical Scribe, ER Scribe, or ED Scribe -- is a trained medical information manager who specializes in charting physician-patient encounters in real-time during medical exams. A medical scribe can work onsite at a hospital or clinic, or from a remote, HIPAA-secure facility. Medical scribes who work at an offsite location are known as virtual medical scribes and normally work in clinical settings. By handling data management tasks for physicians in real-time, free the physician to increase patient contact time, give more thought to complex cases, better manage patient flow through the department, and increase productivity to see more patients What is a Medical Scribe?

3. Healthcare Organizations • Physicians • Licensed Independent Practitioner • Scribe Management Company (Contracted Service) Who Do Scribes Work For?  

4. Core Responsibility: - Capture accurate and detailed documentation of patient encounter • General Duties : Assist the provider in navigating the EHR Respond to various messages as directed by the provider Locating information for review (i.e. previous notes, reports , test and lab results) Entering information into the HER as directed by the provider Researching information requested by the provider Roles & Responsibilities  

5. What Scribes Can’t Do: Make independent decisions or translations while capturing or entering information into the EHR beyond what is directed by the provider. Provide any type of direct patient care. Roles & Responsibilities  

6. Before Scribing: Average time spent on documentation: 1-2 hours per day. After Scribing : Time saved for patient interactions: 30-60 minutes per day. Time Management for Doctors

7. History of Present Illness Review of Systems (ROS) & Physical Exam Vital Signs and Lab Values Results of Imaging Studies Progress Notes Continued Care Plan and Medication Lists Common Documentation Duties