Charting and Scribing


This page is part of the Ophthalmic Assistant Basic Training Course.
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Guidelines for charting:

  • The patient chart is a legal document.  As such, care should be taken to ensure accuracy and legibility.
  • Only use standard abbreviations, otherwise write out the terminology.
  • All entries should be signed and dated.  A log should be kept with signatures, initials, and printed names for proper identification.
  • If an error is made, the erroneous text should not be obliterated.  Do not use white out on a patient chart.  The proper procedure is to draw a single line through the error.  The error should be initialed and dated.

 Job description of a Scribe:

  • The role of the scribe is to assist the physician with documentation of the patient's medical record.
  • The scribe accompanies the physician into the exam room to transcribe the history and examination as given by the patient and the physician.
  • 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 usually directly assist with patient care, but may do so as directed by the physician.
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