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This page is part of the Ophthalmic Assistant Basic Training Course.
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Guidelines for charting:
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The patient chart is a legal document. As such, care should be taken to ensure accuracy and legibility.
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Only use standard abbreviations, otherwise write out the terminology.
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All entries should be signed and dated. A log should be kept with signatures, initials, and printed names for proper identification.
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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.
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Job description of a Scribe:
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The role of the scribe is to assist the physician with documentation of the patient's medical record.
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The scribe accompanies the physician into the exam room to transcribe the history and examination as given by the patient and the physician.
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The scribe, under the direction of the physician, transcribes the impression and plan, results of tests, prescriptions, and orders.
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The scribe documents any procedures that may be performed by the physician or ophthalmic medical personnel.
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The scribe transcribes any consultations or discussions with family members.
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The scribe does not usually directly assist with patient care, but may do so as directed by the physician.
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