The Joint Commission has previously defined scribes as unlicensed personnel and prohibited them from entering orders. However, the previous definition is no longer valid or appropriate due to the emergence of models including licensed and unlicensed personnel of varying skill and clinical knowledge levels. There are individuals with the official title of “scribe” for whom documentation assistance is their only role. Some individuals perform dual functions that include clinical responsibilities and documentation assistance.
All types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Documentation assistants who are not authorized to submit orders should leave the order pending for certified or licensed personnel to activate or submit the orders after verification.