Medical Scribes 101
The use of medical scribes has become more common in recent years, as practices and facilities search for ways to alleviate documentation tasks for providers, thereby improving their overall productivity, Medical scribes are not medical providers (although often scribes may have some medical background), and he or she is never meant to treat a patient. Instead, the scribe’s basic task is to document in the patient medical record. The Joint Commission, which accredits and certifies healthcare organizations and programs, released guidelines in July 2012 to describe the limits of the scribe’s role:
A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner. It is the Joint Commission’s stand that the scribe does not and may not act independently but can document the physician’s or practitioner’s dictation and/or activities.Individual payer policies may go further when defining the scribe’s role. For example, Cahaba specifies that documentation of the scribed services must include:
- Who performs the service
- Who recorded the service
- Qualifications of each person
- Signed and dated by both the physician and the scribe.