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The information recorded may include symptoms, medical history, test results, diagnoses, treatment plans, prescription medications, and progress made at appointments. SOAP notes can help you stay on-track during appointments with patients and quickly complete your notetaking after the session has ended.
A virtual medical scribe is someone who writes down what a doctor and patient say and does during an appointment. Some people call them “medical assistants,” while others call them “documentation assistants,” and sometimes others call them “typists.” Since they are not in the exam room, virtual scribes are less of a bother.
Also document behaviors you hope to avoid. She appeared upset, and set the tone of our appointment by immediately voicing her displeasure with how her symptoms had been managed. After taking a thorough history and performing a full physical examination, her demeanor changed.
Tasks like prior authorizations, quality reporting, messaging patients, and EHR documentation often overflow into after-clinic work. You can create standardized prep sheets for common conditions to empower MAs to anticipate and arrange required tasks, facilitating smoother appointments. Thoughtful delegation benefits your entire team.
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