Medical scribes have been around for a while but are now starting to receive increased attention in the healthcare industry as many more practitioners are turning to their use. With the now commonplace use of EMR/EHR systems to help practitioners stay focus on giving quality patient care and relieve the practitioner from the burden of having to chart patient encounters that are requiring more detailed documentation.
A scribe is an unlicensed person hired to enter information into the EMR or paper chart at the direction of a physician or Licensed Independent Practitioner (LIP), for example a nurse practitioner or physician assistant. The Joint Commission’s (TJC) stand is that they do not endorse nor prohibit the use of scribes. However, if the organization using a scribe is subject to TJC surveys, the surveyors will expect to see compliance with applicable JC standards. Additionally, TJC’s stand is that a scribe does not and may not act independently and does not support scribes being utilized to enter orders for physicians or LIPs due to the additional risk involved in the process.
Overall Roles and Responsibilities of a Scribe
A scribe’s core responsibility is to capture accurate and detailed documentation of the provider encounter. Scribes are clerical personnel who chart for the provider and do not interview or have direct contact with patients. Scribes may not make independent decisions nor translate while entering information into the patient’s health record beyond what is directed by the provider.
It is not recommended to allow an individual to be both a scribe and a medical/clinical assistant during the same encounter as this practice raises issues of job role and responsibility (i.e., scribes have pretty much the same HIPAA security rights as a provider, while a medical/clinical assistant may have limited access to a patient chart based on their scope of practice.)
Documentation Guidelines (per the Joint Commission)
- No verbal orders are to be given to a scribe.
- Name, title, date and timing of all entries should be clearly identifiable and distinguishable from the physician, LIP, or other staff member.
- Affirmation of the provider’s presence during the time the encounter was recorded.
- Authentication by provider the information was reviewed for accuracy.
- Third-party payers may have specific guidelines for how the scribe documents and how the electronic signature must be signed.
Benefits of a Scribe
- Allows the provider to focus more on the patient, with the expectation that more physician face time with the patient hopefully will increase provider and patient satisfaction during the visit.
- Scribes often chart faster, so documentation completed is often available more quickly for review with improvements in overall documentation.
- Scribe documentation often is more detailed and comprehensive than a physician note as the Scribe is charting in “real time,” capturing the details of the patient encounter in the provider’s words.
- A scribe’s notes may help reduce the use of previously used transcription services.
- Improved documentation also may help achieve “meaningful use” incentive criteria by allowing for improved compliance with quality measures for billing and reimbursement.
The good news is an increasing body of research is showing the use of medical scribes has been shown to improve physician/LIP productivity, cost and time savings, better patient satisfaction, and patient safety, especially when the physician/LIP is not electronically savvy and data entry causes fatigue and dissatisfaction.
Susan Jones is a Senior Risk Management & Patient Safety Specialist for the Cooperative of American Physicians, Inc. Questions or comments related to this article should be directed to sjones@capphysicians.com.