A healthcare professional recently inquired about hiring a scribe for their practice. They had concerns regarding patient confidentiality and efficiency in the workplace. The following information includes the responsibilities and advantages of a scribe, in addition to the protocols a practice must follow upon hiring a scribe.

Posted in Risk Management on Wednesday, April 19, 2017

Many studies say hiring a scribe may lead to greater productivity and more accurate documentation of your patient’s health records. However, as with any new position, it is important to analyze and define why your practice should hire a scribe.  This can help clarify the standards and expectations for all employees.  Because a scribe may change the process in your practice, it’s important to monitor and audit the process to incorporate any updates or changes in a timely manner.

Who You Should Hire

At this time, there are no national standards for scribes. Education and experience for scribes can range from a certified professional to an individual with a high school education. The complexity of your practice and your patients may determine what level of expertise you feel may be necessary in the individual you are seeking. Scribes can be someone who is currently working within the practice or someone who is hired as an employee or contracted with through an agency. It will be important that the scribe have the knowledge, personality, and ability to get along with the healthcare professional to whom they will be assigned. 

A training protocol, as with any new employee, should be utilized to orient them to the practice and train them on their role and the responsibility of their position. Whether an employee or contractor, the scribe should have a name badge consistent with the other practice employees. Work evaluations should be completed to confirm the scribe and healthcare professional are abiding by the policies set in place for using the scribe.

A Scribe’s Responsibilities

The scribe should be in the room with the healthcare professional during the entire visit unless the patient objects to the scribe being present. They will be entering information into the EHR as it is received, in the provider’s own words. Therefore, the level of confidentiality and professionalism will be no less than that expected of other members of the healthcare team. The scribe may also perform other clerical duties for the healthcare professional, such as collecting data and navigating the EHR system.

When using a scribe, it is important to remember the healthcare professional is the ultimate responsible party for the notes entered by the scribe. The healthcare professional must sign off on the notes in the EHR, attesting to the fact they have reviewed the information for accuracy. This attestation must be dated and in some instances, include the time. The scribe must also attest in the EHR to the fact they were acting as scribe using their name and title, date and in some situations, the time. It is always wise to check with your practice’s attorney to determine if there are any state regulations which might apply to the use of scribes by certain healthcare professionals such as mid-level providers.

If you have further questions about hiring a scribe, contact us today. For more detailed information on using scribes in a physician practice, read this article.