An article posted by Linda Sullivan of New England Medical Transcription (NEMT) discusses a presentation at this year’s HIMSS conference regarding scribes. In her article, Ms. Sullivan describes some of the discussion in Rise of the Medical Scribe Industry – Risk to EHR Advancement presented by George Gellert, MD, MPH, MPA, and S. Luke Webster, MD of Christus Health. She states, “The speakers expressed concern that unlicensed individuals are entering patient information including CPOE into the EHR. And at times being put in the position of having to make decisions for which they are not trained.”

What a scribe does do: A scribe works at the elbow of the provider entering the documentation into the healthcare record (the EHR). Traditionally, a scribe is physically present throughout the provider/patient encounter. The provider will usually introduce the scribe to the patient by various ways; for example, “Mrs. Jones, Jim is here to help me with the computer so we can spend more time together.” Or, “Mrs. Jones, this is my scribe Jim, who will be assisting me with the documentation of your exam today.” In a clinic, patients are sometimes advised in advance that there will be a scribe in the room unless they object, which they certainly have the right to do. Scribes are trained specifically to understand and enter required elements of documentation in order to obtain maximum reimbursement for providers.

The scribe records:

The History of Present Illness: As the patient is interviewed by the provider, the scribe enters the information presented by the patient. The scribe does not make any independent decisions in this section (usually narrative). The scribe is trained to translate “patient speak” into formal medical language. For example, a patient complains she has had a “stomachache for 3 days…I’ve been sick to my stomach and throwing up nonstop.” The scribe might write, “The patient is a female who presents to the ED today with 3 days of abdominal pain. She states she has had nausea and has been vomiting frequently.” There are no independent decisions or interpretations produced here. The scribe may also use quotation marks if the information is unable to be translated or is best stated as a quote.

The Review of Systems: In an EHR, the ROS is customarily recorded by utilizing checkboxes and is noted as positive or negative pertinent findings, depending on what the provider asks the patient, as well as the acuity level of the patient. As the provider interviews the patient, the scribe checks the correct details. Sometimes these checkboxes populate into a narrative paragraph in the document. The scribe does not interview the patient, nor does he/she determine what belongs in the ROS (besides, occasionally, the Chief Complaint).

The Past Medical/Surgical/Social/Family Histories: These are usually prepopulated from patient’s previous encounters; if not, the medical assistant or nurse may interview the patient and enter this information or the patient may fill out a paper chart. When the scribe is present in the room with the provider, if the patient remembers something in this section that was not told to the MA or nurse, the scribe may enter the information.

The Physical Exam: Again, this information is entered by the scribe while the provider is performing the exam. Most often the provider will dictate this information to the scribe during the exam: “Abdomen is soft and nontender. Heart has a regular rate and rhythm. Lungs are clear.” The scribe is not allowed clinical judgment or independent entering of any of this critical information. Sometimes the provider will not be comfortable dictating this information during the exam and will dictate the information to the scribe after they have left the room.

Medical Decision Making/Assessment and Plan: MDM is traditionally known as the “voice” of the provider. This may be completely dictated/scribed by the provider, or it may be dictated to the scribe, or there may be a standard template the scribe will utilize, which the provider then can add to as needed. For example, four standard sentences may be used here: a summary of why the patient is being seen (The patient is a female who presents today for abdominal pain); a brief summary of the physical exam (On exam today, abdomen is soft and nontender); differential diagnoses (Differential diagnoses include but are not limited to:…); and the plan (Today I will order a CBC, chest x-ray, and a UA). Again, a scribe is not allowed to use independently created information to create a patient chart.

Traditionally, scribes are pre-med students looking for clinical hours in their gap year between university studies and medical school. It is a true statement that scribes are unlicensed individuals; however, after 200 hours of clinical practice, a scribe is eligible to become certified through the ACMSS. This is not a mandatory exam and is not routinely paid by a scribe’s employer, but it does lend some credibility to a scribe’s ability and skill level. Still, scribes undergo a steep learning process in a short period of time, unless the scribe is an experienced HDS or MA already (which makes for an ideal scribe). A pre-med student is not interested in becoming a full-time permanent employee, resulting in a high level of attrition and a training and hiring process that can seem never-ending for a healthcare facility, whereas an experienced HDS or MA can be a solution to these issues.

Ms. Sullivan also states that an audience member wanted to know the difference between a scribe and a medical language specialist (aka medical transcriptionist/healthcare documentation specialist). “Dr. Webster responded that patient information entered by a medical scribe is not the same thing as the process of dictation/transcription. ‘It’s not a fair analogy because the process of dictation and transcription still involves the physician as the central actor intellectually and cognitively. That content is generated by the skill set, training and experience of that physician cumulatively.’ ” This is at best an inaccurate statement. Dictation/transcription is traditionally done after the fact–that is, after the patient encounter is completed. The chart is customarily completed at the point of care (POC) in real time. Transcription is customarily completed and returned to the client 24-72 hours later, depending on many factors–ESL provider dictation, unintelligible audio, etc. A provider can still dictate findings or any other section of the EHR to the scribe, which is then transcribed into the record. The provider is still the author of the record. The provider is still completely and totally responsible for the content of that record. That provider is still the “central actor,” whether the record is traditionally transcribed from an audio file or completed by a scribe at the POC. This argument holds no water. One advantage to having a scribe at hand is the ability for the scribe to verify and confirm what the provider has dictated. No blanks are left in a document. Traditional medical transcription must sometimes leave blanks in a document due to unintelligible dictation or the fact that the HDS has no way to communicate with the provider and cannot fill these in.

Yes, it is true that a patient may not want a scribe in the room, but this issue can easily be solved by good communication between the provider and patient. It is simple to dictate findings to the scribe outside the room. Another way around this is to have a remote, or virtual, scribe. The scribe can be located outside the facility or in a separate department in the facility and in audio communication with the provider. Hospitals who have eliminated their transcription departments may be well served by training those employees to become scribes and work alongside the providers whose work they are used to transcribing.

What a scribe does NOT do: Diagnose; make independent decisions or judgments regarding a patient’s care or treatment; choose orders including labs and/or medications; change what the patient says to completely change the context or meaning; perform or assist with any procedures, even the most benign.

The Joint Commission does not recommend scribes entering CPOE; however, certified scribes, especially those who are already CMAs, may enter and pend orders for the provider to sign in a clinic environment.

A top-notch training and quality program can eliminate many of the errors one might see with inexperienced scribes. AHDPGTM provides training for both beginning and allied health professional scribe students and also provides training and implementation services to clients who are considering using scribes in their facilities.