Best Practices for Working With Scribes

One way that medical practices have chosen to deal with the increasing burden of electronic health records (EHRs) is to use medical scribes. Scribes help document patient encounters by capturing data in electronic charts, retrieving diagnostic results, and providing proper coding. This allows physicians to communicate with patients face-to-face without the barrier of a computer screen. Both patients and physicians are able to better focus on the visit, not the EHR—and physicians can be more productive, effective, and present.

Recent studies suggest that the benefits of having medical scribes go beyond enhancing patient interactions and can include improved physician satisfaction and increased practice revenue. In fact, a recent study by the National Center for Biotechnology Information, which took a close look at the impact of scribes on a cardiology practice, showed physicians with scribes generated an additional revenue of more than $24,000 by producing clinical notes that were coded at a higher level.

There are, however, potential drawbacks to having scribes on staff.

First, it can be difficult to find and retain a good scribe. There is often high turnover. Some scribes are medical school students, and are therefore, only available for short-term experience. Turnover can be frustrating for practices since the amount of training required for a new scribe is time-consuming.

Furthermore, since medical scribes are a relatively new idea in health care, there is minimal information around the legal issues that have emerged as a result of using scribes. There are currently no certification requirements, and the minimal qualification is a high school diploma. Regulatory agencies have not forbidden the use of scribes, but regulatory requirements and guidance around the role differ. As a result of these differing guidelines and requirements, scribes may have different responsibilities and restrictions in various care settings.

Given the lack of consistent guidance, here are some key considerations for practices looking to involve scribes:

• Scribes cannot act independently. The Joint Commission, an organization that accredits and certifies thousands of health care organizations and programs in the U.S., permits scribes to document physicians’ dictations and/or activities but does not permit them to act independently, with the exception of obtaining past family social history and a review of systems.
• Providers are ultimately responsible for scribe documentation.The Joint Commission indicates that scribes should sign and date all entries they make in an EHR. The scribe must use his or her own identifiable login/password when documenting in the EHR. A licensed practitioner should then authenticate the entry by signing and dating it, as well as adding a time stamp if applicable.It is imperative that the physician review and sign the documentation and notes from each visit to make sure they are accurately entered.
• Practices should develop and maintain a policy on scribes. It is highly recommended that any practice using the services of a scribe have a policy that defines the documentation and auditing processes for the role. It should be understood that the scribe’s role is to provide better documentation and that the scribe is not there to question the physician’s clinical judgement or to add or change documentation on their own. It is also important for practices to review state laws to ensure compliance and proper use of scribes by mid-level providers.

Curi  offers member practices the following tools to help them manage and reduce risk related to scribes (and other unlicensed assistive personnel):

• • Policy: Medical Scribe Documentation
  • Agreement: Medical Scribe
  • Documentation Review Electronic Medical Record
  • Documentation Review Medical Record
  • Documentation Review Staff Signature List

• Members can also contact our Risk Management team for further support on this issue at 800-328-5532.