Medical scribe

Medical Scribe

A Medical Scribe (pronunciation: /ˈmɛdɪkəl skraɪb/) is a healthcare professional who assists physicians by documenting patient information in real-time during medical examinations.

Etymology

The term "Medical Scribe" is derived from the Latin word "scribere," meaning "to write," and the prefix "medical," which pertains to the practice of medicine.

Role and Responsibilities

A Medical Scribe's primary role is to transcribe and document patient data during a medical examination. They assist physicians by recording patient histories, documenting physical examinations, and noting the results of laboratory tests. Scribes also assist in managing electronic health records (EHRs) and may be involved in the coordination of patient care.

Training and Qualifications

Medical Scribes typically have a background in health sciences or pre-medical studies. They undergo specialized training to understand medical terminology, HIPAA regulations, and EHR systems. Certification may be obtained through organizations such as the American College of Medical Scribe Specialists (ACMSS).

Related Terms

Electronic Health Record (EHR): A digital version of a patient's paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.
Physician: A professional who practices medicine, which is concerned with promoting, maintaining, or restoring health through the study, diagnosis, prognosis, and treatment of disease, injury, and other physical and mental impairments.
Transcribe: To make a written copy of spoken language, or to make a copy of written language in a different form.