A medical scribe is an assistant to the physician who is responsible for documenting patients’ family and medical histories, treatments, allergies, lab results and any information dictated to them or relevant to the patient’s visit. However, they are not responsible for deciding the patient’s treatment or their care. A medical scribe’s primary duties are to follow a physician through his or her work day and chart patient encounters in real-time using a medical office’s electronic health record (HER) and existing templates. Responsibilities will vary with the scribe’s department rules. Medical scribes generate referral letters for physicians, book appointments and manage and sort medical documents within the HER system. Some scribes assist with e-prescribing (this is prohibited in some jurisdictions and allowed in others). Scribes also find information and people (such as medical records from other hospitals, test results or on-call consultants).

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