What Is a Medical Scribe?
The Joint Commission defines a medical scribe as an unlicensed individual hired to enter information into the EHR or chart at the direction of a physician or licensed independent practitioner. Physician practices, hospitals, emergency departments (EDs), long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers all use scribes. Scribes can be employed by a healthcare organization, physician, or licensed independent practitioner. They can also be subcontracted from a scribe service.
"A medical scribe shares the provider's burden of data gathering and EHR documentation," explains emergency physician Michael Murphy, MD, Founder and CEO of ScribeAmerica, a scribe vendor based in Aventura, Florida. "In doing so, the physician's individual productivity and patient throughput increase, so that the goal of providing cost-effective, quality medical care is achieved."
"A medical assistant or nurse takes the patient's weight and vital signs and accompanies the patient to an exam room," Toth explains. "The scribe accompanies the physician when he or she enters the exam room and records the history, examination, treatment plan, and other clinical data in real time, while the physician interacts with the patient.
"The scribe does additional typing and other documentation while the physician moves on to the next room," she continues. "At the end of the clinic session, the physician reviews the documentation and makes any corrections to the scribe's documentation and signs off."
"Scribing is not merely listening to a doctor dictate a note and typing it into the EHR," adds Shariff. "It is interpreting the physician-patient interaction and converting it into a concise document with relevant information, then doing appropriate coding to send to the coders/billers, while also creating the letter to the referring physician and doing all the associated tasks."
"The physician-scribe relationship goes beyond transcription," Toth agrees. "For example, scribes remind physicians of treatment plans and other recommendations from previous visit notes and provide a check-and-balance system to ensure visit documentation requirements are met, test results are received, and prescriptions are refilled."
Scribes aren't licensed coders or otherwise licensed, but they do receive from 3 weeks to 3 months of training, depending on the vendor, during which they learn, among other things, clinical terminology and common CPT codes for the specialties for which they are being groomed as well as compliance with Health Insurance Portability and Accountability Act (HIPAA) patient privacy mandates.
Of course, scribes are also trained to use a client doctor's EHR. Typically younger adults for whom computers are second nature, they can click their way through complex software with jaw-dropping speed. Because different EHRs are similar in design, a scribe can generally master a new EHR in about 3 days, Shariff says. Physicians Angels supports over 25 of the most popular EHRs.
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Cite this: Hate Dealing With an EHR? Use a Scribe and Profits Increase - Medscape - Feb 27, 2014.