The primary role of the scribe in the Emergency Department (ED) is to assist the Physician with documenting the medical chart of each patient and their stay in the ED. Physician shall introduce the Scribe to the patient as being present to document the Physician’s dictation of the care provided.
1. The Scribe accompanies the Physician into the patient examination room in order to transcribe the history and physical exam as stated by the Physician during the interview and examination of the patient.
2. The Scribe transcribes any procedures done by the Physician.
3. The Scribe must sign and date all entries into the medical record, whether electronic or manual, which clearly identifies their role as the Scribe, documenting for the physician. Such signature must include “(enter name of Scribe) acting as scribe for Dr. (insert physician name)” with the date and time of the entry by the Scribe.
4. The Scribe will not transcribe any physician orders.
5. The Scribe assists in completing the chart by tracking the status of the results of any lab, x-ray, or other evaluations and will continually check on the progress of this data.
6. The Scribe transcribes any consultations or discussions with family and/or the patient’s private physician or on call physician or any specialty services.
7. The Scribe accompanies the Physician and documents any re-examinations of the patient.
8. The Scribe transcribes the proper diagnosis, discharge or follow-up instructions, and/or prescriptions on to the record as dictated by the Physician.
9. The Scribe assists in the organization of the Physician by maintaining a comprehensive list of active patients while in the ED. This includes the status of labs, consults, procedures and re-evaluations of each patient.
10. The Scribe is strictly prohibited from any involvement in direct patient care.
11. Demonstrates knowledge of and competently performs technical procedures.
12. Provides care and performs duties in accordance with the plan of care, unit routine, and hospital policy.
13. Maintains a safe, secure environment for patients, visitors and co-workers
14. Performs delegated responsibilities in which education and training has been provided and competency assessed.
15. Uses equipment properly
16. Upholds the patient’s rights in the provision of care
17. Promotes infection control and safety as it relates to the patient and employee environments
1. Communicates with Emergency Center Physicians, the Registered Nurses and members of healthcare team.
2. Conveys information completely and timely
3. Effectively interacts with others
4. Delivers excellent customer service by exhibiting the Beaumont Standards
5. Demonstrates knowledge, understanding and embraces cultural traditions and lore of community served.
6. Provides assistance to individuals in a manner that takes into account their special needs and age-related needs.
Requirements: High School diploma; Medical Terminology; Typing Skills 50wpm
Preferred Skills: Scribe experience, medical field training or education