Is a Nurse Who Enters Physician Orders a 'Scribe'?

Carolyn Buppert, NP, JD

Disclosures

September 13, 2012

Question

What is the difference between a 'scribe' and a nurse who enters information in the electronic health record as directed by the physician?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert P.C., Bethesda, Maryland

This question was submitted as a follow-up to Who Can Enter Computerized Orders for Physicians?

There are several differences between a nurse and a scribe. A "scribe" is, by definition, an unlicensed individual who is entering information while a physician or advanced practice provider is present and dictating the information to be entered. The scribe has no ability or authority to make medical decisions and is simply a conduit from physician (or advanced practice provider) to computer, for the sake of efficiency. Another difference is that a scribe has no duty to a patient and therefore is never going to be sued. The physician or advanced practice provider speaking the orders or information retains all of the responsibility. Finally, a scribe is not subject to any state laws on scope of practice, because the scribe has no "practice." So a scribe can't be reported to a licensing board.

A nurse has a duty to a patient and can be sued. A nurse functions under state laws on scope of practice and can be disciplined by a Board of Nursing if that scope of practice is exceeded. A nurse can act in the role of a scribe, because no law prevents a registered nurse from entering orders or other information into a computer while a physician stands there and speaks the words. However, that would be a very inefficient use of the nurse's time.

Sometimes a nurse has knowledge of the appropriate orders to be written, so rather than the physician speaking every detail to the nurse entering them into the computer, the nurse is left to fill in the blanks. However, it is inappropriate and illegal for a physician to give vague directions to a nurse, who then enters orders and/or treatment decisions. In that situation, because the nurse doesn't have all of the information that the physician has, doesn't have all of the education and training that the physician has, and cannot read minds, the nurse could get it wrong. If the nurse gets it wrong, the nurse is going to pay a price, whether it is employee discipline, discipline from the Board of Nursing, or a lawsuit.

Contrast these 2 examples:

  • Example 1: Physician to nurse: "Please enter this order for Jane Doe: Lasix 40 mg PO BID for 3 days."

  • Example 2: Physician to nurse: "Let's start her on some Lasix, as usual."

The order entry in example 1 is legal. Example 2 is illegal, because the registered nurse (if he or she is not an advanced practice nurse) does not have the scope of practice to decide on the dose, route, timing, and duration. The nurse in example 1 still is taking a risk, because the nurse could mishear the patient's name, medication dose, route, or duration or the nurse could make a typographical error, but the risk involved in example 1 is far less than in example 2.

I see no reason for nurses to subject themselves to these risks, so my advice to nurses is: Don't do it (neither example 1 nor example 2). Each person should enter his or her own orders and write his or her own progress notes.

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