The role of the scribe is to assist the physician with documentation of the patient's medical record. A scribe explains to the patient what the patient should expect from technician's work up and from the physician. Scribes completes a detailed patient history which includes past medical history (systemic and ocular), family medical history (systemic and ocular), medication history (systemic and ocular) and the chief complaint (the reason for the visit).
The scribe, under the direction of the physician, transcribes the impression and plan, results of tests, prescriptions, and orders.
The scribe documents any procedures that may be performed by the physician or ophthalmic medical personnel.
The scribe transcribes any consultations or discussions with family members.
The scribe does not directly assist with patient care.
Attends required staff and educational meetings as requested.
Maintains strictest confidentiality.
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