Job Summary
A Scribe is an unlicensed position that does not and may not act independently but assists with the Physician’s or licensed independent practitioner’s dictation and/or activities. The role of the scribe is to increase physician productivity and reduce patient length of stay by helping to manage a patient’s journey through the department. The scribe will anticipate the needs of their assigned provider and department flow by monitoring lab results, radiology reports, and consults as well as ensuring prompt communication with other healthcare staff. In addition, the scribe will work to improve patient satisfaction by updating patients on wait times as well as helping to facilitate re-evaluations and reminding their physicians of prescriptions and discharge instructions. All assistance will be under the direct oversight and control of the physician, and subject to the physician’s review and approval of actions taken to facilitate documentation and communication during patient care. The support activities provided by the Scribe under the physician’s direct oversight and control are intended to improve patient flow and satisfaction. Such activities may include:
Tracking the various elements of the patient chart to notify the physician when all documentation requirements are complete.
Facilitating the communication and coordination between the physician and other components of patient care such as tests, labs, imaging, and medical records,
Other administrative or clerical support required by the physician.
SPECIFIC DUTIES, RESPONSIBILITIES, AND LIMITATIONS
Gathering Data
Scribes may gather laboratory results and medical records and other data for review by the physician. Data should not be entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician.
Scribes must continuously check on the progress of this data in order to get the patient’s workup complete so that the physician is able to make treatment decisions.
Communication
The Scribe may not provide verbal orders or relay verbal orders between the Physician and other patient care providers. For example, communicating “The doctor wants the patient to have 5 mg of morphine.” is not permissible. The Physician must communicate orders directly to other care providers.Scribes may communicate that orders have been written. For example “The doctor wrote orders for the patient.” or, “the discharge paperwork is on the chart.” is an allowable communication for Scribes.
Scribes can make and answer calls for the Physician, however Scribes may not take medical data, (radiology reports, lab values, etc.) over the phone.
Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.
Scribes can communicate waits and delays as directed by the RN or Physicians.
Direct Patient Care
Scribes may not engage in any direct patient care such as direct patient contact, (e.g. lifting patients from backboard, transporting, or assisting in security issues.) Scribes may not assist techs in their roles of cleaning wounds, applying splints, CPR, setting up suture trays or drawing blood.
Scribes may not bring patients food or water.
Scribes may bring patients blankets subject to the approval of the physicians or other licensed provider.
Prescriptions
Scribes may not have access to narcotic prescription blanks or lock box.
Disposition
Scribes may gather the depart process at the Physician’s direction. Scribes may not put depart paperwork on the chart without the Physician’s review.
Scribes may not disposition patients
Supervisory Requirements
Scribes will not supervise others, but may conduct scribe training.
REQUIRED QUALIFICATIONS (KNOWLEDGE, SKILLS, ABILITIES)
High School Diploma or Equivalent
Some college level coursework in pre-med related courses (i.e. biology, chemistry, physics)
Working knowledge of medical terminology and accepted abbreviations
Satisfactory completion of any hospital screening requirements such as criminal background checks, drug screening, and health screening Satisfactory completion of any hospital or privacy training
Satisfactory completion of the ScribeCanada training program
Computer proficiency and ability to quickly learn new applications
Typing speed of 60+ WPM
Communication skills and the ability to coordinate and cooperate with multiple members of the healthcare team
Organizational skills with focus on tracking patient care and improving patient flow Professional demeanor and recognition of privacy considerations for patients and families
Bilingualism (English and French) for all Quebec sites
SPECIAL DEMANDS
Flexibility in scheduling
Coping with the sometimes high-pressure enviroment
WORK ENVIRONMENT
Emergency Department
PHYSICAL DEMANDS
Standing for long periods of time
Frequent walking for short distances
Repetitive motion work with keyboards, physical writing
