I’m not really sure how to start this introduction, but here we go! My name is Keaira. Yes, I will only give my first name for security purposes. From the title you may or may not be able to guess that I am a scribe. What is a scribe you ask? Well a scribe (a medical scribe as in my case) is an individual who helps make physicians lives a whole lot easier by completing the medical records for each patient. Physicians over the past couple of years have been switching from paper charts to computer record charts. With physicians wanting to spend more time tending to the patient and less time completing charts, this is where I and my colleagues come in. A scribe can work in an outpatient facility such as a doctors office. Or work inpatient such as on the wards in the hospital or in the emergency department. I work in the emergency department. I constantly get asked about my occupation and to put it simply (very simply) I do the documentation for physicians in real time of when they interact with patients. Just to be clear, I AM NOT A CLINICIAN AND CANNOT GIVE ADVICE ON DIAGNOSIS, NOR CAN I MAKE A DIAGNOSIS. To me, this is not enough to fully explain the extent of what I do.
I created this blog to help give individuals a glimpse into what a scribe does. Well specifically, what I do. Hence, why I chose the name “Just Scribing Along”. So, to protect the patients I see and where I work, I will change any characteristics that may identify an individual or the place where I work. All names will also either be changed or not used at all. This is to protect both the patients and myself as well as stay in compliance with HIPPA. If you don’t know what HIPPA is, I suggest you look it up!
Just kidding. HIPPA stands for Health Insurance Portability and Accountability Act of 1996. This protects all information and medical documentation about a patient. There are severe repercussions if this law is broken including but not limited to a fine ($100-100,000 per violation and up to 1.5 million per year) and I could also loose my job. So to avoid all of the above, I will not mention any identifying information about the patients I interact with.
I pray this evolves to more then my scribe experience and a way for me to have an outlet from the stressful filled days in the emergency department. So thanks for coming along on my journey and I pray a blessed day for everyone.