virtual medical scribe checklist

Patient Information

Verify patient demographic details (name, date of birth, contact information)

Confirm insurance information and eligibility

Record chief complaint or reason for visit

Medical History

Update patient's medical history, including past surgeries, allergies, and chronic conditions

Document current medications and dosages

Note any known family medical history

Vital Signs

Record patient's blood pressure, pulse rate, temperature, and respiratory rate if available

Document height and weight if available

Symptom Assessment

Document patient's symptoms and their duration

Record any pain levels or severity ratings reported by the patient

Note any associated symptoms or factors that worsen or relieve the symptoms

Ask the patient about the specific location of the symptoms

Inquire about the frequency and timing of the symptoms

Determine if there are any triggers or specific activities that exacerbate the symptoms

Assess if the symptoms have been progressively worsening or improving over time

Investigate if there are any factors that provide relief or mitigate the symptoms

Evaluate if there are any patterns or trends associated with the symptoms

Ask the patient if there are any other symptoms or concerns related to the main complaint

Determine if the symptoms are affecting the patient's daily activities or quality of life

Inquire about any previous treatments or interventions tried by the patient to alleviate the symptoms

Ask if there have been any recent changes in medications, diet, or lifestyle that may be related to the symptoms

Assess if the patient has any family history of similar symptoms or conditions

Physical Examination

Document findings from the physical examination if provided by the healthcare provider

Record any abnormalities or relevant observations

Diagnostic Tests

Note any ordered laboratory tests, radiology exams, or other diagnostic procedures

Document the reason for the test and any special instructions for the patient

Treatment Plan

Record the healthcare provider's diagnosis or impression

Document prescribed medications, including dosage and frequency

Note any recommended lifestyle modifications or referrals to specialists

Patient Education

Document any instructions given to the patient regarding their condition, treatment, or self-care

Provide educational materials or resources as needed

Follow-Up

Schedule any necessary follow-up appointments or referrals

Record instructions for follow-up communication or monitoring

Documentation and Coding

Ensure accurate and complete documentation of all relevant information

Assign appropriate medical codes for billing and reimbursement purposes

Review and Sign-Off

Review the entire virtual medical scribe checklist for accuracy and completeness

Obtain necessary signatures or approvals from the healthcare provider or supervisor

Remember, the specific checklist items may vary depending on the healthcare facility and the requirements of the virtual medical scribe role.