Virtual Medical Scribe Pre-Charting: What to Prepare Before a Patient Visit

Virtual medical scribe pre-charting is the process of reviewing and organizing relevant patient information in the electronic health record (EHR) before a scheduled appointment. A virtual medical scribe may review previous clinical notes, patient history, medications, allergies, laboratory results, imaging reports, and appointment details to help prepare the chart for the physician.

For U.S. medical practices, organized pre-visit chart preparation provides a clearer starting point for patient encounters. It helps physicians identify relevant background information, recognize documentation gaps, and understand what information may need further discussion during the appointment.

A structured pre-charting workflow also helps virtual scribes coordinate with physicians and medical assistants before the consultation begins. However, chart preparation does not replace clinical judgment. Physicians remain responsible for evaluating patient information, making clinical decisions, reviewing documentation, and finalizing clinical notes.

What Is Virtual Medical Scribe Pre-Charting?

Virtual medical scribe pre-charting is a preparation activity performed before a patient encounter. The scribe accesses the patient's authorized EHR information, reviews relevant records, and organizes existing documentation according to the practice's established workflow.

Depending on the appointment type and physician preferences, this preparation may include:

• Reviewing previous office visit notes and medical history.
  
• Checking documented medications and allergies.
  
• Reviewing available laboratory results and imaging reports.
  
• Identifying relevant diagnoses and ongoing treatment history.
  
• Checking previous referrals and follow-up documentation.
  
• Preparing the appropriate EHR note template.
  
• Organizing information that may require physician clarification.

For example, before a patient arrives for a diabetes follow-up, the scribe may review previous progress notes, available glucose-related laboratory results, documented medications, and earlier treatment discussions.

This information gives the physician a convenient overview of the existing record. It does not determine whether a treatment should change or whether a diagnosis should be added.

Why Is Pre-Visit Chart Preparation Important?

Patient appointments involve more than documenting the conversation. Physicians may need to review previous encounters, examine test results, discuss ongoing symptoms, and consider relevant medical history.

When important information is spread across different EHR sections, locating it during the appointment can interrupt the clinical workflow.

A consistent virtual medical scribe pre-visit workflow helps organize this information before the consultation.

1. Provides an Organized Patient History

Reviewing previous clinical notes gives the physician context about earlier visits, documented concerns, and ongoing treatment.

A scribe can organize relevant historical information so the physician can refer to it during the encounter.

2. Makes Relevant Results Easier to Locate

Available laboratory reports, imaging records, and diagnostic results may be relevant to the upcoming appointment.

Pre-charting helps identify and organize these records without interpreting findings or making clinical conclusions.

3. Supports Medication and Allergy Review

The scribe can review the medication and allergy information documented in the EHR and identify entries that may need confirmation.

The physician or designated clinical team member must verify current medications, allergies, and any necessary changes with the patient.

4. Helps Identify Documentation Gaps

Missing information, incomplete follow-up notes, unavailable reports, and outdated entries can be identified for the appropriate team member to review.

This allows unresolved items to be brought to the physician's attention rather than silently treated as confirmed information.

5. Creates a More Consistent Documentation Workflow

When scribes follow an agreed preparation process, patient charts can be organized more consistently across appointments.

This is particularly useful for practices managing recurring visits, multiple providers, and specialty-specific documentation requirements.

What Should a Virtual Medical Scribe Review Before a Patient Visit?

The information reviewed should depend on the patient's appointment type, the practice's protocols, and the physician's documentation preferences.



The following EHR sections provide a practical starting point.

1. Patient Demographics and Appointment Details

Begin by confirming the correct patient record and upcoming appointment.

Review:

• Patient name and available identifiers.
  
• Appointment date and scheduled time.
  
• Visit type and assigned physician.
  
• Relevant demographic information.
  
• New-patient or established-patient status.
  
• Available appointment notes and scheduling information.

Patient identity must be verified using the practice's established procedures. A similar name or appointment description should never be treated as sufficient confirmation.

2. Previous Clinical Notes and Medical History

Review relevant previous encounters to understand the patient's documented medical background.

Depending on the appointment, this may include:

• Previous progress notes.
  
• Medical and surgical history.
  
• Documented chronic conditions.
  
• Relevant family and social history.
  
• Previous assessment and treatment documentation.
  
• Earlier follow-up recommendations.

The objective is to organize existing information, not rewrite the patient's medical history or assume that old information remains current.

3. Medication and Allergy Information

Review the medication and allergy sections of the EHR.

Check for:

• Documented prescription medications.
  
• Recorded dosage and frequency information.
  
• Medication changes documented in previous encounters.
  
• Listed allergies and recorded reactions.
  
• Available medication reconciliation notes.
  
• Entries that appear incomplete or require confirmation.

A medication listed in the EHR should not automatically be considered an actively used medication. The physician or clinical team should confirm the current medication list with the patient.

4. Laboratory Results and Imaging Reports

Identify available diagnostic information relevant to the upcoming appointment.

Examples include:

• Previous laboratory reports.
  
• Blood test results.
  
• Radiology and imaging reports.
  
• Diagnostic procedure documentation.
  
• Pending or previously requested investigations.
  
• Relevant specialist reports.

A virtual medical scribe can organize the location and status of available reports for physician review. The scribe should not independently interpret results, diagnose conditions, or determine treatment implications.

5. Diagnoses, Referrals, and Follow-Up Records

Review existing documentation related to the patient's ongoing care.

This may include:

• Previously documented diagnoses.
  
• Referral records.
  
• Specialist consultation notes.
  
• Follow-up instructions.
  
• Previous treatment documentation.
  
• Relevant preventive care and screening records.

If a referral or report is unavailable, the scribe should flag it according to the practice's communication protocol rather than assume it has been completed.

6. EHR Templates and Documentation Preferences

Before the appointment, the scribe should understand the physician's preferred documentation format.

This may involve:

• SOAP note structure.
  
• Specialty-specific note templates.
  
• Required EHR fields.
  
• Preferred terminology and abbreviations.
  
• Relevant documentation sections.
  
• Physician-specific formatting preferences.

This preparation helps the scribe follow the practice's existing clinical documentation workflow.

Virtual Medical Scribe Pre-Charting Checklist

Medical practices can use the following checklist to standardize patient chart preparation before appointments.

Patient chart review checklist

• Confirm the correct patient record.
  
• Check the appointment date, time, and visit type.
  
• Review relevant previous clinical notes.
  
• Check documented medical and surgical history.
  
• Review the recorded medication list.
  
• Review documented allergies and reactions.
• Locate relevant laboratory results.
  
• Locate available imaging and diagnostic reports.
  
• Review existing diagnoses and relevant problem-list entries.
  
• Check previous referrals and follow-up records.
  
• Identify missing or incomplete documentation.
  
• Prepare the appropriate EHR note template.
  
• Organize relevant information for physician review.
  
• Communicate unresolved items through the agreed workflow.

Not every item will apply to every appointment. Practices should adapt the checklist to their specialty, visit type, EHR configuration, and internal policies.

How Does the Virtual Medical Scribe Pre-Visit Workflow Work?

An organized pre-visit workflow involves coordination between the physician, medical assistant, and virtual medical scribe.

Step 1: Review the Upcoming Appointment Schedule

The scribe reviews the authorized appointment schedule and identifies the patients assigned to the physician.

The visit type and available appointment information help establish which records may be relevant.

Step 2: Access the Patient's EHR

The scribe accesses the appropriate patient chart using the practice-approved access process.

The correct patient record must be confirmed before reviewing or preparing documentation.

Step 3: Review Relevant Patient Information

The scribe examines available clinical history, previous notes, medications, allergies, imaging, and laboratory records relevant to the upcoming visit.

The review should follow the practice's established instructions and avoid unnecessary access to unrelated patient information.

Step 4: Organize Information for the Encounter

Relevant existing information is organized according to the physician's preferences and the practice's EHR structure.

Missing reports, incomplete entries, or items requiring clarification are identified for the appropriate team member.

Step 5: Coordinate With the Physician or Medical Assistant

If an important document is unavailable or information needs confirmation, the scribe communicates the issue through the agreed channel.

Clinical questions should be directed to the physician or designated clinical professional.

Step 6: Support Real-Time Encounter Documentation

Once the physician begins the consultation, the virtual medical scribe can document relevant encounter information in the EHR in real time.

The scribe follows the physician's instructions and the established documentation workflow.

Step 7: Leave Documentation for Physician Review

After the encounter, the physician reviews the documentation, makes necessary corrections, and finalizes the clinical note.

The scribe's preparation and documentation support do not replace physician approval.

How Does Pre-Charting Differ Across Medical Specialties?

The information reviewed before a patient appointment varies according to the specialty and reason for the visit.

Primary Care

Pre-charting may include chronic condition history, medication lists, previous progress notes, available laboratory results, and preventive care records.

Orthopedics

Relevant preparation may include previous orthopedic notes, available imaging reports, injury history, surgical records, and documented mobility or functional assessments.

Cardiology

The scribe may locate previous cardiology notes, available ECG reports, echocardiogram documentation, medication records, and relevant diagnostic results.

Pediatrics

Preparation may involve previous pediatric notes, recorded growth measurements, immunization documentation, developmental history, and caregiver-related information.

Psychiatry

Relevant records may include previous psychiatric progress notes, documented medication history, treatment follow-ups, and available mental health assessments.

In every specialty, the physician determines which information is clinically relevant and how it should influence the encounter.

Common Virtual Medical Scribe Pre-Charting Mistakes to Avoid

A structured checklist is useful, but practices should also establish clear safeguards.

1. Reviewing the wrong patient chart

Always follow the practice's patient identification and verification procedures before accessing or preparing records.

2. Treating outdated information as current

Previous medication lists, diagnoses, and history entries may no longer reflect the patient's current situation. Flag information that requires confirmation.

3. Missing relevant reports

A laboratory test or imaging study may be available in a different EHR section. Follow a defined review process and communicate unavailable records.

4. Making clinical assumptions

A scribe should never independently diagnose a patient, interpret results as a clinical conclusion, or recommend changes to treatment.

5. Using inconsistent documentation formats

Different note structures can create unnecessary editing and review work. Follow the physician's established templates and preferences.

6. Failing to communicate unresolved items

Missing reports and incomplete records should be communicated to the appropriate team member before the encounter whenever possible.

7. Overlooking privacy and access procedures

Practices should establish appropriate access permissions, confidentiality requirements, secure communication methods, and workforce training for anyone handling patient information.

How Chase Clinical Documentation Supports Pre-Visit Chart Preparation

Chase Clinical Documentation provides virtual medical scribe services for U.S. healthcare practices that need support with patient chart preparation and clinical documentation.

Its virtual medical scribes review patient information in the EHR before physician encounters, helping organize relevant historical information and prepare charts according to the practice's documentation workflow.

Depending on the practice's requirements, preparation may involve reviewing:

• Previous patient notes and documented medical history.
  
• Available imaging and diagnostic records.
  
• Relevant medication and allergy information.
  
• Appointment details and visit-specific documentation requirements.

Chase also supports real-time clinical documentation within the EHR during patient encounters.

The service supports major EHR platforms, including Epic, athenahealth, eClinicalWorks, Cerner/Oracle Health, NextGen, and other systems, subject to workflow and access requirements.

Dedicated virtual medical scribe assignments and specialty-specific documentation support help practices establish workflows suited to their physicians.

The service can support both in-person and telehealth appointments.

For practices considering remote documentation support, explore Chase Virtual Medical Scribe Services to understand the available service and workflow options.

Prepare Your Patient Charts With a Structured Virtual Scribe Workflow

Effective pre-visit chart preparation begins with a consistent process for reviewing patient history, medications, allergies, previous notes, and relevant diagnostic records.

A virtual medical scribe can support this process by organizing existing EHR information before appointments and documenting encounters in real time. The physician remains responsible for clinical decisions, reviewing documentation, and final approval.

For practices looking to establish a more organized clinical documentation workflow, Chase Clinical Documentation offers dedicated virtual medical scribe support tailored to physician and specialty requirements.

Request a Free Consultation to discuss your practice's EHR, specialty, and patient chart preparation requirements.