With documentation becoming more than just a word and EHR becoming a reality, most offices are trying to find ways to work more efficiently. EHRs just don't seem like awesome replacements for sliced bread, especially if you've been practicing just fine without them for your entire professional career. However, they are taking over, whether you want them to or not. One of the best ways to cope with and EHR and its additional documentation and coding, yet still keep your sanity and your patient satisfaction can be for the doctor to continue being a doctor and dealing with patients face-to-face, while someone else scribes (or documents) patient encounters for the doctor – getting down all of the vital patient information, the doctor findings and responses, and any work done, as well as the recommended treatment plan.
Notice that I listed “scribe/scribing” as a function or job, rather than as a person. Although you could have a dedicated scribe in a dedicated scribe position, the person doing the scribing might actually be an MA/CA, nurse, NP, coder, or other assistant. The purpose of a scribe is to scribe. Basically to jot down and note the information dictated to them by an appropriate provider, whom they are directly working with. This frees up the provider to provide more personalized and focused care to their patients, while still getting down all of the information necessary to properly bill out and receive payment for the visit. It can also save a lot of valuable time for the provider freeing up extra time for a few more patients, while at the same time freeing them up to go home at a “normal” time to spend quality time with their families.
There are people of both sides of the fence regarding using a “scribe” in their practice. It seemed like a lot of it broke down to what type of practice and what you expected of your scribe. Above the money that could be made, and the time and frustration that could be saved, the number one joy of having a great scribe was that the provider regained their life and free time (because they could leave the office at the end of the day, rather than at the end of the paperwork).
Now that you’re thinking having a scribe might be super nifty…. Let’s talk about some of the do-s and don’t s of scribing in a medical environment. First off, scribes are not licensed, but they can be trained to various levels. More training generally makes someone more useful. If you are a specialty, or even a busy practice, you will want to allow time to work with and train your scribe your specialty specifics, methods, needs, and office flow. Everything done and documented by a scribe IS under the supervision of the rendering provider. They do not work alone, and there is no separate line item for a scribe, scribing. [1]
DOs
DO always remember and remind your scribe that they are on the front line, with you, for HIPAA patient data protection. It is not to be discussed or shown to anyone but the doctor and the person coding and billing out. It is private!
DO document who is doing the documenting and who is performing the services. [2]
For each encounter the scribe should document who did the service (with their qualifications), what was done, notes and such as dictated by the provider, who is scribing, the date, and it needs to be signed and dated by both the scribe and any providers. (This includes noting who is doing the note taking and data updating for HPI or reviews of previous data or follow-up. Who is noting and documenting that information – scribe, NP, LPN, RN, CA, etc… needs to be documented in the note, with a date, and credentials- if appropriate. [3a & 3b])
DO introduce your scribe and their function to the patient when they are in the room with you. I saw cases mentioned where it was inappropriate or uncomfortable for the scribe to be in with the doctor (i.e. a female scribe when the doctor is doing a prostate exam, or a male scribe with a doctor doing a female exam, etc.) in those cases the doctor either dictated after or there were several who had the scribe on comms (on a communications ear piece of some sort) in another room where they took down the info the doctor dictated during the exam.
DON'Ts
DON’T let your scribe “pre-populate” templates for you. That would make it “not” part of your exam and outside of your performed exam items. (They can populate it while you review the information with the patient – that IS part of the exam.)
DON’T let your scribe pull in/cut-n-paste previous info into your new encounter for you (see previous DON’T).
DON’T let your scribe “create” your note. The provider dictates the note, the scribe writes it down. They aren’t you. They just document you.
DON’T let your scribe independently document additional details of an encounter outside of your exam room and dictate. A scribe adding to the patient note or record, after the fact, isn’t scribing, it’s creating. They are not there to write, they are there to scribe (write down).
A scribe can remind a provider that they forgot a meaningful use measure or that they still need detail (like the length of the incision or what particular method or test is being used, if the provider forgot to tell them in course), but they can only record what actions were provided and dictated. [4]
When in doubt-check. Check with CMS (as most people follow CMS guidelines) and/or any of your other insurance companies that you might be concerned about. You may also want to check out the HIPAA guidelines and/or your office’s legal help to make sure that everything you want to do is appropriate and safe to do. Another good step is looking at scribe training (if you want one of your staff to act in that position) or get a trained scribe. Even though they aren’t credentialed as a scribe – there is training and you can have a trained scribe.
[1] http://cgsmedicare.com/partb/pubs/news/2012/0412/cope18560.html
[2] http://www.cahabagba.com/news/guidelines-for-the-use-of-scribes-in-medical-record-documentation-2/
[3a & b] “Can ancillary staff act as a scribe for a provider?”/“What specific information can ancillary staff document during an evaluation and management (E/M) encounter?”
[3a] http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Medicare~Resources~FAQs~EM%20Help%20Center~8EELQE6434?open&navmenu=Resources%7C%7C%7C%7C
[3b] https://www.aapc.com/memberarea/forums/showthread.php?t=64462
[4] http://www.kevinmd.com/blog/2014/03/confessions-medical-scribe.html
[Additional]
Scribes in the Hospital: A Detailed Look
http://blogs.hallrender.com/blog/scribes-in-the-hospital-a-detailed-look/
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