![]() ▪ Assist the clinician in navigating the EMR ▪ Follow site downtime protocol when necessary, offer to help other scribes or clinicians with physician charts ▪ Alert the clinician when the physician chart is ready for their review ▪ Seek out missing or previously not dictated information from clinicians to complete the physician chart ▪ Keep clinicians informed of resulting diagnostics and troubleshoot delays in those results. ▪ Ensure documentation meets requirements for risk management, billing, etc. and document relevant information into the EMR. ▪ Actively listen to all conversations pertaining to patient care between the clinician and other healthcare providers, patients, family, etc. Place phone calls to PMD offices, pharmacies, etc. outpatient diagnostics, nursing home records, EMS run sheets, etc.). ▪ Gather and input patient information from external sources (e.g. ▪ Document clinician’s dictations into the EMR, that reflect the full complexity of care provided including patient history, physical exams, procedures, orders, diagnostics, medications and conversations with the patient, family, or consulting clinicians ▪ Take verbal dictations or take notes while accompanying clinicians in patient rooms A medical scribe does not act independently, but documents the clinician’s previously determined dictation and/or activities in the electronic medical record (EMR). The medical scribe job allows the clinician to focus on each patient, spend more time at the bedside, and work more efficiently. ![]() In addition, the Lead Scribe continues to work clinical scribe shifts at the same location to provide documentation assistance and scribe services in the Emergency and Hospitalist Medicine Departments at the direction of a Physician or Advanced Practice Provider (Nurse Practitioner or Physician Assistant). ![]() This includes managing scribe job performance (training, coaching, mentoring) creating the site monthly scribe schedule liaison between site clinicians, corporate management, and scribes. Under the direction of the Director and Associate Director of Practice Enhancement, the Lead Scribe supervises the scribe staff at their assigned RWJBH facility. ![]()
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