The review process indicates a scenario where a medical scribe faces a conflict between patient privacy and a physician’s request, highlighting the critical ethical and regulatory responsibilities of a scribe. This situation is professionally challenging because it pits the scribe’s duty to protect patient confidentiality against a direct instruction from a supervising physician, potentially creating a stressful environment where the scribe must navigate competing obligations. Careful judgment is required to uphold ethical standards and legal mandates without jeopardizing the physician-patient relationship or the scribe’s professional standing. The best approach involves prioritizing patient confidentiality and adhering to established privacy protocols. This means politely but firmly declining the physician’s request to share information outside of the authorized patient record, explaining that doing so would violate privacy regulations. The scribe should then offer to document the information appropriately within the patient’s electronic health record, ensuring that all access and sharing of information follows the established legal framework and institutional policies designed to protect patient data. This upholds the principle of patient autonomy and the legal requirement for data privacy, which are paramount in clinical practice. An incorrect approach would be to immediately comply with the physician’s request without question. This fails to recognize the scribe’s independent ethical and legal obligations regarding patient privacy. Such compliance could lead to a breach of confidentiality, violating regulations designed to protect sensitive patient information and potentially exposing the healthcare facility to legal repercussions and reputational damage. Another incorrect approach would be to ignore the physician’s request and proceed with other tasks without addressing the situation. This demonstrates a lack of professional communication and problem-solving skills. It fails to uphold the scribe’s duty to both the patient and the physician by not clarifying the boundaries of acceptable information sharing and not ensuring the accurate and secure documentation of patient data. A further incorrect approach would be to discuss the physician’s request with other staff members who are not directly involved in the patient’s care. This constitutes an unauthorized disclosure of patient information and a breach of confidentiality, even if the intent is to seek advice. It undermines the trust placed in the scribe to handle sensitive information discreetly and in accordance with privacy laws. Professionals should approach such situations by first understanding their ethical and regulatory obligations. When faced with a request that seems to conflict with these obligations, they should pause, assess the request against established policies and laws (such as HIPAA in the US context, or equivalent privacy legislation), and communicate their concerns clearly and respectfully to the requesting party. If clarification is needed, they should seek guidance from their supervisor or the institution’s compliance officer. The goal is always to find a solution that respects patient privacy, adheres to legal requirements, and supports effective patient care.

This scenario is professionally challenging because it involves a direct conflict between a patient’s expressed wishes and a healthcare provider’s perception of their best interest, complicated by the potential for a serious medical condition. Navigating this requires a delicate balance of respecting patient autonomy, ensuring patient safety, and adhering to legal and ethical obligations regarding informed consent and medical decision-making. Careful judgment is required to avoid coercion while still ensuring the patient receives appropriate care. The best approach involves a thorough and documented discussion with the patient about the risks and benefits of the recommended diagnostic imaging, ensuring they understand the potential consequences of refusing the scan. This approach is correct because it upholds the principle of patient autonomy, a cornerstone of medical ethics and law. By engaging in a detailed conversation, the scribe facilitates informed consent, allowing the patient to make a decision based on a clear understanding of their situation. Documenting this discussion is crucial for legal protection and demonstrates due diligence in the care process. This aligns with the ethical duty to respect a patient’s right to refuse treatment or diagnostic procedures, provided they have the capacity to make such decisions. An incorrect approach would be to proceed with scheduling the scan without further discussion, assuming the patient’s initial refusal was uninformed or a temporary reaction. This fails to respect patient autonomy and bypasses the essential process of informed consent. Ethically, it can be seen as paternalistic and potentially coercive. Legally, proceeding without explicit, informed consent could lead to accusations of battery. Another incorrect approach would be to immediately involve the patient’s family or friends to persuade them to agree to the scan, without first exhausting direct communication with the patient. While family involvement can be supportive, overriding a competent adult patient’s wishes through third-party pressure is ethically problematic and can undermine trust. It also risks violating the patient’s privacy and right to make their own healthcare decisions. Finally, an incorrect approach would be to document the patient’s refusal without any attempt to understand the reasons behind it or to provide further information. This passive approach neglects the scribe’s role in facilitating clear communication and ensuring the patient is making an informed decision. It fails to address potential underlying fears or misunderstandings that might be influencing the patient’s choice, and it does not fulfill the ethical obligation to promote patient well-being through informed decision-making. Professionals should use a decision-making framework that prioritizes open communication, patient education, and respect for autonomy. This involves actively listening to the patient’s concerns, providing clear and understandable information about medical recommendations, and documenting all interactions and decisions thoroughly. When faced with a patient’s refusal of a recommended procedure, the professional should explore the patient’s reasoning, address any misconceptions, and reiterate the potential benefits and risks, always ensuring the patient has the capacity to make the decision.

Scenario Analysis: This scenario is professionally challenging because it requires the apprentice medical scribe to balance the immediate need for accurate documentation with the patient’s right to privacy and the physician’s need for focused patient interaction. Misinterpreting or failing to capture key information can lead to incomplete medical records, impacting patient care and potentially violating regulatory requirements for documentation accuracy. The scribe must be attentive without being intrusive, ensuring all critical details are noted without disrupting the therapeutic relationship. Correct Approach Analysis: The best professional practice involves actively listening to the patient and physician, identifying and noting down salient details related to the chief complaint, history of present illness, review of systems, physical examination findings, assessment, and plan. This approach ensures comprehensive and accurate documentation by focusing on the core components of a medical encounter. Regulatory frameworks, such as those governing medical records and patient privacy (e.g., HIPAA in the US, or equivalent data protection laws in other jurisdictions), mandate that medical records be accurate, complete, and timely. Capturing key information directly addresses these requirements by ensuring the record reflects the actual encounter and the physician’s clinical reasoning. Ethical considerations also support this approach, as accurate documentation is fundamental to providing safe and effective patient care. Incorrect Approaches Analysis: One incorrect approach is to focus solely on transcribing the physician’s spoken words verbatim without actively identifying and extracting the key clinical information. This can result in a transcript that is verbose but lacks the structured, clinically relevant data required for a medical record. It fails to meet the implicit requirement of a medical scribe to synthesize and organize information, potentially leading to an incomplete or poorly organized chart that hinders future clinical decision-making and may not meet regulatory standards for record completeness. Another incorrect approach is to interrupt the patient or physician to ask clarifying questions about every piece of information that seems unclear. While clarification is important, excessive interruption disrupts the flow of the patient encounter, can agitate the patient, and distract the physician. This can lead to a less effective consultation and may inadvertently cause the omission of other crucial details due to the disruption. It also demonstrates a lack of independent judgment in discerning what information is essential versus what can be inferred or clarified later through established protocols. A further incorrect approach is to rely on assumptions or to fill in gaps in the documentation based on prior knowledge or common practice without direct observation or physician confirmation. Medical records must reflect the specific details of the patient encounter. Making assumptions can introduce inaccuracies into the patient’s chart, which is a serious ethical and regulatory violation. Inaccurate documentation can lead to misdiagnosis, inappropriate treatment, and legal repercussions, directly contravening the principles of patient safety and data integrity. Professional Reasoning: Professionals should employ a systematic approach to information gathering during patient encounters. This involves understanding the standard structure of a medical note (e.g., SOAP format), actively listening for keywords and phrases related to each section, and developing the ability to discern clinically significant information from general conversation. When in doubt, it is preferable to note the ambiguity and seek clarification from the physician during or immediately after the encounter, rather than making assumptions or omitting critical data. Adherence to established documentation guidelines and an understanding of the legal and ethical implications of medical records are paramount.

Scenario Analysis: This scenario presents a professional challenge for an apprentice medical scribe due to the sensitive nature of patient health information and the legal and ethical obligations surrounding its use. The core challenge lies in balancing the need to accurately document patient encounters within the Electronic Health Record (EHR) system with the imperative to protect patient privacy and maintain data integrity. Missteps in handling EHR access or data entry can lead to breaches of confidentiality, inaccuracies in patient records, and potential violations of healthcare regulations, all of which can have serious consequences for the patient, the healthcare provider, and the scribe. Careful judgment is required to ensure all actions align with established protocols and legal mandates. Correct Approach Analysis: The best professional practice involves strictly adhering to the established organizational policies and procedures for EHR access and data entry. This means logging into the EHR system only with authorized credentials, using the system solely for assigned duties during scheduled work hours, and accurately transcribing dictated or provided information directly into the patient’s chart without personal interpretation or modification. This approach is correct because it directly aligns with the principles of patient privacy (e.g., HIPAA in the US context, or equivalent data protection regulations elsewhere), data security, and professional accountability. Authorized access and accurate, unbiased data entry are fundamental to maintaining the integrity and confidentiality of patient records, which is a cornerstone of ethical medical practice and regulatory compliance. Incorrect Approaches Analysis: Using personal login credentials to access the EHR system for a colleague who is experiencing technical difficulties is a significant regulatory and ethical failure. This action constitutes unauthorized access and potentially violates patient privacy by allowing someone without direct patient care responsibility to view protected health information. It also compromises data security and audit trails, making it difficult to track who accessed what information and when. Sharing personal login credentials with a colleague to allow them to complete documentation tasks is another serious breach. This is a direct violation of security protocols designed to protect patient data. It bypasses individual accountability and can lead to unauthorized access, data manipulation, and a breakdown in the audit trail, all of which are critical regulatory concerns. Accessing the EHR system outside of scheduled work hours to “catch up” on documentation without explicit authorization or supervision is also professionally unacceptable. This can lead to unauthorized access to patient information outside of a direct patient care context, potentially violating privacy regulations. It also raises concerns about data accuracy and completeness if the scribe is not actively engaged in the patient encounter or receiving real-time information. Professional Reasoning: Professionals should approach EHR system use with a mindset of strict adherence to policy and a commitment to patient privacy. The decision-making process should involve: 1) Understanding and internalizing all organizational policies and procedures related to EHR access, data entry, and patient confidentiality. 2) Recognizing that EHR systems are secure environments with audit trails, meaning all actions are logged. 3) Prioritizing patient privacy and data security above all else. 4) Seeking clarification or assistance from supervisors or IT support when encountering technical issues or uncertainties, rather than resorting to unauthorized workarounds. 5) Maintaining professional boundaries and ensuring all actions are directly related to assigned duties and patient care.

Scenario Analysis: This scenario is professionally challenging because it requires the apprentice medical scribe to accurately document a patient’s condition while adhering to strict privacy regulations and ensuring the integrity of medical records. The scribe must balance the need for comprehensive documentation with the ethical and legal obligation to protect patient confidentiality. Misinterpreting or misrepresenting information can lead to diagnostic errors, inappropriate treatment, and breaches of privacy, all of which have serious consequences for patient care and professional standing. Correct Approach Analysis: The best professional practice involves meticulously documenting the patient’s reported symptoms and the physician’s objective findings related to the cardiovascular system, using precise medical terminology. This approach is correct because it directly supports accurate medical diagnosis and treatment planning by providing a clear, factual record of the patient’s presentation. Adherence to established medical terminology ensures clarity and avoids ambiguity, which is crucial for effective communication among healthcare providers. Furthermore, this method upholds the principle of accurate record-keeping, a fundamental ethical and regulatory requirement for all healthcare professionals, including scribes. Incorrect Approaches Analysis: One incorrect approach involves omitting details about the patient’s reported chest pain and shortness of breath because they were not directly observed by the physician. This is professionally unacceptable because it creates an incomplete and potentially misleading medical record. Patient-reported symptoms are vital diagnostic clues, and their omission violates the scribe’s duty to capture a comprehensive patient history. Another incorrect approach is to interpret the patient’s occasional cough as a significant respiratory issue without explicit physician confirmation, and then documenting it as such. This constitutes unauthorized medical interpretation and diagnosis, which is outside the scope of a scribe’s role and can lead to inaccurate charting and patient management. Finally, documenting the patient’s history of hypertension as “high blood pressure” without using the specific medical term “hypertension” is also an incorrect approach. While seemingly minor, the use of precise medical terminology is essential for standardized record-keeping and clear communication within the healthcare system, and deviations can lead to misunderstandings or misclassification of conditions. Professional Reasoning: Professionals should approach medical documentation with a commitment to accuracy, completeness, and adherence to scope of practice. This involves actively listening to both the patient and the physician, using precise medical terminology, and distinguishing between reported symptoms and physician observations. When in doubt about terminology or the significance of a finding, a scribe should seek clarification from the supervising physician rather than making assumptions or interpretations. The primary goal is to create a factual and unambiguous record that aids in patient care and complies with all relevant regulations.

Scenario Analysis: This scenario is professionally challenging because the medical scribe must ensure the accuracy and clarity of patient documentation while navigating the inherent ambiguity of medical abbreviations. Misinterpreting or misusing an abbreviation can lead to significant patient safety risks, including incorrect diagnoses, inappropriate treatments, or medication errors. The pressure to document efficiently must be balanced with the absolute necessity of precision and adherence to established standards. Correct Approach Analysis: The best professional practice involves prioritizing clarity and patient safety by using full medical terms when there is any doubt about the unambiguous interpretation of an abbreviation. This approach directly aligns with the core ethical duty of a medical scribe to produce accurate and reliable documentation that supports effective patient care. Regulatory frameworks, such as those governing medical record-keeping and patient safety, implicitly or explicitly mandate that documentation must be understandable and free from ambiguity that could compromise care. Using full terms when an abbreviation’s meaning is uncertain ensures that all healthcare professionals involved in the patient’s care can interpret the record correctly, thereby preventing potential errors and upholding the integrity of the medical record. Incorrect Approaches Analysis: One incorrect approach involves assuming the meaning of an abbreviation based on context alone, even when multiple interpretations are possible. This fails to meet the standard of accuracy required in medical documentation. Regulatory guidelines emphasize the importance of unambiguous records, and relying on assumptions introduces a significant risk of misinterpretation, which could lead to patient harm. This approach violates the principle of due diligence in medical record-keeping. Another incorrect approach is to use an abbreviation that is not universally recognized or is specific to a particular institution without ensuring its clear definition within the patient’s chart or a readily accessible institutional glossary. This creates a barrier to understanding for any healthcare provider who may not be familiar with that specific abbreviation, potentially leading to confusion and errors. Professional standards and regulatory requirements for medical records stress the need for clarity and accessibility to all authorized personnel. A further incorrect approach is to abbreviate terms that are already concise and commonly understood in their full form, solely for the sake of perceived efficiency. While efficiency is a consideration, it should never supersede accuracy and clarity. This practice can introduce unnecessary ambiguity and does not demonstrably improve the documentation process when the full term is easily written and universally understood. It deviates from the primary goal of creating a clear and comprehensive medical record. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes patient safety and regulatory compliance. When encountering a medical abbreviation, the scribe should first consider if its meaning is absolutely unambiguous and universally understood. If there is any doubt, or if the abbreviation is not standard, the scribe must default to using the full medical term. This requires a proactive approach to understanding institutional policies on abbreviations and a commitment to continuous learning about common and potentially ambiguous abbreviations. The scribe should always ask themselves: “Could this abbreviation be misinterpreted by another healthcare professional, and if so, what is the potential consequence for the patient?”

Scenario Analysis: This scenario is professionally challenging because it requires the apprentice medical scribe to accurately interpret and document patient information, which directly impacts patient care and medical record integrity. Misinterpreting or misusing medical terminology can lead to diagnostic errors, inappropriate treatment, and potential patient harm. The apprentice must demonstrate not only knowledge of common terms but also the ability to apply this knowledge in a real-time clinical setting, adhering to professional standards and the specific documentation requirements of the healthcare facility. Correct Approach Analysis: The best professional practice involves accurately transcribing the physician’s dictated terms, ensuring correct spelling and context, and seeking clarification when unsure. This approach is correct because it directly aligns with the core responsibilities of a medical scribe: to create a faithful and accurate record of the patient encounter. Regulatory frameworks for medical documentation emphasize accuracy and completeness. Ethically, this ensures the patient’s medical record is a reliable source of information for all healthcare providers involved in their care, preventing miscommunication and potential medical errors. Incorrect Approaches Analysis: One incorrect approach involves assuming the meaning of a term based on context without verification. This is professionally unacceptable because it introduces a high risk of misinterpretation. Medical terms can have multiple meanings, and context alone may not be sufficient for accurate understanding. This failure violates the principle of accuracy in medical documentation and could lead to incorrect diagnoses or treatments, posing a direct risk to patient safety. Another incorrect approach is to use a synonym for a term that the scribe is unfamiliar with, without confirming its precise meaning and applicability in the clinical context. This is professionally unacceptable as it bypasses the opportunity to learn and ensure accuracy. Synonyms may not be perfectly interchangeable, and using an incorrect synonym can alter the clinical meaning of the physician’s documentation, leading to confusion and potential errors in patient management. It also fails to uphold the scribe’s duty to accurately reflect the physician’s dictation. A further incorrect approach is to omit the term from the record entirely due to uncertainty. This is professionally unacceptable because it results in an incomplete and inaccurate medical record. The physician’s dictation is intended to be part of the patient’s permanent record, and omitting information, even due to uncertainty, compromises the integrity of that record. This can hinder subsequent healthcare providers’ understanding of the patient’s condition and treatment plan, potentially impacting future care decisions. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes accuracy, clarity, and adherence to established protocols. When encountering unfamiliar medical terms, the primary steps should be: 1) attempt to understand the term within the immediate clinical context, 2) if still uncertain, consult reliable medical dictionaries or terminology resources, and 3) if ambiguity persists or the term is critical, politely and professionally seek immediate clarification from the dictating physician. This systematic approach ensures that all documentation is accurate, complete, and ethically sound, safeguarding patient well-being and maintaining professional integrity.

The assessment process reveals a scenario where an apprentice medical scribe is tasked with documenting a patient’s condition. This situation is professionally challenging because the scribe must accurately translate complex medical information, including the underlying pathophysiology, into clear and concise documentation while adhering to strict privacy regulations and professional ethical standards. Misinterpreting or misrepresenting the pathophysiology can lead to incorrect treatment plans, patient harm, and regulatory violations. Careful judgment is required to ensure the documentation is both medically accurate and compliant. The correct approach involves the apprentice scribe accurately documenting the patient’s signs and symptoms as observed and reported, and then, based on the physician’s explicit dictation or confirmed diagnosis, noting the underlying pathophysiological processes. This is correct because it prioritizes direct observation and physician-led diagnosis, aligning with the scribe’s role as a recorder of information and a support to the physician. Regulatory frameworks, such as HIPAA in the US, mandate the protection of patient health information and require that documentation accurately reflects the patient’s condition and the care provided. Ethical guidelines for medical professionals emphasize accuracy, integrity, and patient safety, which are upheld by this method. An incorrect approach would be for the apprentice scribe to independently research and infer the patient’s pathophysiology, then document this inference as a definitive finding without explicit physician confirmation. This is professionally unacceptable because it oversteps the scribe’s scope of practice, potentially introducing inaccuracies and misdiagnoses. It violates the principle of accurate medical record-keeping and could lead to patient harm if the inferred pathophysiology is incorrect. Furthermore, it bypasses the physician’s authority and responsibility for diagnosis, creating a significant ethical and regulatory breach. Another incorrect approach is for the apprentice scribe to document only the patient’s subjective complaints and objective findings, omitting any mention of the underlying pathophysiology even when it has been clearly diagnosed and dictated by the physician. This is professionally unacceptable as it results in incomplete medical documentation. Accurate and comprehensive medical records are essential for continuity of care, billing, and legal purposes. Omitting confirmed pathophysiological details, when provided by the physician, represents a failure to fulfill the scribe’s duty to accurately record the patient’s medical status as determined by the attending physician. A final incorrect approach is for the apprentice scribe to use generic, non-specific terms to describe the patient’s condition, even when the physician has provided detailed information about the specific pathophysiological mechanisms at play. This is professionally unacceptable because it fails to capture the nuance and specificity required for effective medical care and communication. While avoiding overly technical jargon is sometimes appropriate, deliberately using vague language when precise information is available and dictated by the physician undermines the purpose of detailed medical charting and can hinder subsequent medical decision-making. Professionals should employ a decision-making framework that prioritizes accuracy, adherence to scope of practice, and clear communication. This involves actively listening to and accurately transcribing physician dictation, seeking clarification when unsure, and understanding the boundaries of their role. When faced with complex medical information, the scribe’s primary responsibility is to record what is communicated by the physician or directly observed, rather than to interpret or infer beyond their defined duties.

The assessment process reveals a common challenge for apprentice medical scribes: accurately documenting patient encounters while adhering to strict privacy and terminology standards. This scenario is professionally challenging because misinterpreting or misrepresenting medical terminology can lead to significant patient care errors, legal repercussions, and breaches of patient confidentiality. The apprentice must demonstrate not only an understanding of medical terms but also the ethical and regulatory framework governing their use. The best professional approach involves meticulously verifying the patient’s chief complaint and associated symptoms against established medical terminology, ensuring that the documentation accurately reflects the physician’s assessment and plan. This approach is correct because it prioritizes patient safety and regulatory compliance. Specifically, it aligns with the core principles of medical documentation, which demand accuracy, clarity, and completeness. Furthermore, it upholds the ethical obligation to maintain patient confidentiality by ensuring that only relevant and accurately documented information is recorded, thereby preventing the dissemination of potentially misleading or incomplete data. This meticulousness is crucial for maintaining the integrity of the patient’s medical record. An incorrect approach would be to rely on colloquial or layman’s terms when documenting a patient’s complaint, even if the patient uses them. This is professionally unacceptable because it introduces ambiguity and can lead to misinterpretation by other healthcare professionals. Medical records must use precise, standardized terminology to ensure clear communication and avoid diagnostic errors. Another incorrect approach would be to assume the meaning of a symptom based on a general understanding, without confirming it with the physician or consulting reliable medical resources. This is professionally unacceptable as it bypasses the physician’s clinical judgment and the established process for accurate medical record-keeping. Such assumptions can lead to the documentation of incorrect diagnoses or treatment plans, directly impacting patient care and potentially violating professional standards. A further incorrect approach would be to document a symptom using terminology that is not commonly recognized or is overly technical without proper context, even if it is technically accurate. This is professionally unacceptable because it hinders effective communication among the healthcare team. While precision is important, clarity and accessibility of information are paramount in a medical record. The goal is to create a record that is understandable and useful to all authorized personnel involved in the patient’s care. The professional reasoning process for similar situations should involve a commitment to continuous learning and verification. When encountering unfamiliar terminology or uncertain patient descriptions, an apprentice scribe should always: 1) actively listen and observe during the patient encounter, 2) consult reliable medical dictionaries and resources for accurate definitions, 3) seek clarification from the supervising physician or clinician, and 4) cross-reference documented information with the patient’s electronic health record for consistency. This systematic approach ensures accuracy, promotes patient safety, and upholds regulatory and ethical standards.

The assessment process reveals a scenario where a medical scribe must accurately document a patient’s neurological examination findings. This is professionally challenging because the neurological exam is complex, requiring precise terminology and an understanding of anatomical structures and physiological functions. Misinterpreting or inaccurately documenting findings can lead to diagnostic errors, inappropriate treatment, and patient harm. Careful judgment is required to ensure the documentation reflects the clinician’s observations without introducing personal bias or misinterpreting medical terminology. The best professional practice involves meticulously transcribing the exact findings as dictated by the supervising physician, using precise anatomical and physiological terminology. This approach ensures fidelity to the clinical encounter and relies on the physician’s expertise for interpretation. Regulatory compliance in medical documentation emphasizes accuracy, completeness, and adherence to established medical terminology. Ethical obligations require the scribe to act as a neutral observer and recorder, avoiding any action that could compromise patient care or the integrity of the medical record. An approach that involves inferring or adding details not explicitly stated by the physician is professionally unacceptable. This constitutes a deviation from the scribe’s role as a recorder and introduces the risk of misinterpretation or fabrication, violating the principle of accurate documentation and potentially leading to medical errors. Such an action could also be seen as practicing medicine without a license, a serious regulatory and ethical breach. Another professionally unacceptable approach is to use generalized or layman’s terms when specific anatomical or physiological terms were used by the physician. This compromises the precision and clarity of the medical record, hindering effective communication among healthcare providers and potentially leading to misunderstandings about the patient’s condition. It fails to meet the standards of professional medical documentation. A further professionally unacceptable approach is to omit findings that the scribe believes are insignificant. The scribe’s role is to document what is observed and dictated, not to make subjective judgments about the clinical relevance of findings. Omitting information, even if perceived as minor, can deprive other healthcare professionals of crucial data for diagnosis and treatment planning, thereby compromising patient care and violating documentation standards. Professionals should employ a decision-making framework that prioritizes accuracy, adherence to instructions, and ethical conduct. This involves active listening, seeking clarification when unsure, and strictly adhering to the role of a recorder. When faced with complex medical terminology or procedures, the scribe should rely on the supervising physician for guidance and confirmation, rather than making assumptions or independent interpretations. The ultimate goal is to create a medical record that is a true and accurate reflection of the patient’s encounter.