A medical scribe is a person, or paraprofessional, who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe (in the emergency department), or just scribe (when the context is implicit). A scribe is trained in health information management and the use of health information technology to support it. A scribe can work on-site (at a hospital or clinic) or remotely from a HIPAA-secure facility. Medical scribes who work at an off-site location are known as virtual medical scribes.
Medical Scribe Duties
A medical scribe’s primary duties are to follow a physician through his or her work day and chart patient encounters in real-time using a medical office’s electronic health record (EHR) and existing templates. Responsibilities will vary with the scribe’s department rules. Medical scribes generate referral letters for physicians, book appointments and manage and sort medical documents within the EHR system. Some scribes assist with e-prescribing (this is prohibited in some jurisdictions and allowed in others). Scribes also find information and people (such as medical records from other hospitals, test results or on-call consultants). Medical scribes can be thought of as data care managers and clerical personal assistants, enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours. Medical scribes, by handling data management tasks for physicians in real-time, free the physician to increase patient contact time, give more thought to complex cases, better manage patient flow through the department, and increase productivity to see more patients.
The introduction of electronic health records has revolutionized the practice of medicine. However, the complexity of some systems has resulted in providers spending more time documenting the encounter instead of speaking with and examining the patient. A tool which was intended to alleviate some problems of clinical documentation has caused many problems for the very people who were supposed to benefit from the technology – the providers. As a result, providers are experiencing burnout and dissatisfaction. An increasing body of research has shown the use of medical scribes is usually, but not always, associated with improved overall physician productivity, cost- and time-savings. Patients tolerate scribes well and no differences in patient satisfaction can be found when scribes are present. An in-depth study conducted by The Vancouver Clinic in Vancouver, WA from 2011-2012 found that medical scribes improved the quality of clinical documentation and allowed doctors to see extra patients, while noting the risks associated with scribe turnover and doctors’ unfamiliarity with the scribe concept. Most physicians like working with scribes and many authors recommend that healthcare providers employ medical scribes to reduce time spent performing data entry and other administrative tasks, which can increase physician fatigue and dissatisfaction.
With the use of a scribe, physicians are able to see more patients without the hindrance of typing the patient’s chart. Further, because a scribe’s responsibility is focused on charting, the chart is likely to be more thorough and results in more accurate billing to insurance.
Information credit to Wikipedia and FindNurse.org