Capturing the story of Care

Medical scribing is a privilege that allows me to support healthcare providers in documenting patient care. I strive to create accurate and detailed records, working humbly alongside clinicians to capture patient stories, diagnoses, treatments, and outcomes. With a focus on precision and attention to detail, I aim to assist in updating patient records, medical histories, and data entry, acknowledging the trust placed in me to handle sensitive information. I recognize that my role is not just about documentation, but about contributing to the care team's ability to deliver exceptional patient care. I approach each encounter with humility, grateful for the opportunity to serve in this capacity and support the healthcare team in their noble work.

Work Terms

#CC (Chief Complaint), #HPI (History of Present Illness), #ROS (Review of Systems), #PE (Physical Examination), #Assessment, and #Plan. These elements help healthcare professionals document patient care effectively. Additionally, #CPTCodes and #ICD10Codes are used for billing and coding purposes. All these details are stored in an #EHR (Electronic Health Record) or #EMR (Electronic Medical Record)