Daisy | Medical Scribe AI

Physicians (MD/DO)

Attending Physician

• Overall responsibility for patient care, leading the healthcare team.
• Diagnoses conditions, develops treatment plans, prescribes medication.
• Supervises residents, fellows, medical students, and potentially APPs.
• Signs off on notes written by trainees.
• Requires comprehensive documentation like History & Physical (H&P), Progress Notes, Discharge Summaries reflecting complex decision-making.

Resident/Fellow

• Physicians undergoing postgraduate training in a specialty or subspecialty.
• Provides direct patient care under attending supervision.
• Writes detailed notes (H&Ps, progress notes) that are reviewed and co-signed by attendings.
• Similar to Attending (H&P, Progress Notes, Consults), often more detailed for training purposes.

Advanced Practice Providers (APPs)

Physician Assistant (PA)

• Practices medicine collaboratively with or under the supervision of a physician (state laws vary).
• Conducts histories, physical exams, diagnoses, treats illnesses, orders/interprets tests.
• May perform procedures and prescribe medication.
• Often writes H&P, SOAP Notes, Progress Notes, Discharge Summaries, similar in scope to physicians depending on setting.

Nurse Practitioner (NP)

• Advanced practice registered nurses with graduate education.
• Focus on health promotion, disease prevention, diagnosing/managing acute and chronic conditions.
• Practice authority varies by state (some have full practice authority).
• Writes H&P, SOAP Notes, Progress Notes, often focusing on holistic patient care and education.

Nursing Staff

Registered Nurse (RN)

• Provides direct patient care, administers medications, performs treatments, assesses patients' conditions.
• Educates patients and families, coordinates care with other team members.
• Documents assessments, interventions, patient responses, care plans.
• Nursing Notes, Medication Administration Record (MAR), Intake/Output, Flowsheets, Care Plans, Patient Education documentation.

Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN)

• Provides basic nursing care under the direction of RNs or physicians.
• Administers medications (scope varies by state), takes vital signs, monitors patients.
• Often contributes to Nursing Notes, documents Vitals, basic care provided.

Other Clinical Support Staff

Medical Assistant (MA)

• Performs administrative and clinical tasks in outpatient settings (clinics, offices).
• Takes vital signs, prepares patients for examination, collects specimens, schedules appointments.
• May document chief complaint (CC), vitals, patient history elements into the EHR.
• Documents CC, Vitals, sometimes ROS updates, administrative notes.

Medical Scribe

• Assists physicians or APPs directly by documenting the patient encounter in real-time in the EHR.
• Enters HPI, ROS, Physical Exam findings, assessment and plan as dictated or directed by the provider.
• Helps manage EMR flow, tracks lab/radiology results.
• Does NOT make clinical decisions or provide patient care.
• Focuses on accurate and efficient real-time EHR entry for the provider.

Technicians (e.g., Radiology Tech, Lab Tech, EKG Tech)

• Perform diagnostic tests or procedures (X-rays, blood draws, EKGs).
• Document test execution, specimen collection details, sometimes basic patient observations related to the procedure.
• Test Logs, Specimen Collection records, Procedure notes (limited scope).

Therapists

Physical Therapist (PT), Occupational Therapist (OT), Speech-Language Pathologist (SLP), Respiratory Therapist (RT), etc.

• Provide rehabilitation or therapeutic care based on their specialty.
• Assess patient function, develop treatment plans, provide interventions.
• Document evaluations, treatment sessions, progress towards goals.
• Therapy Evaluations, Therapy Notes, Progress Reports, Discharge Summaries specific to their discipline.