Q. What does a scribe do?
A: Medical scribes observe and document in real-time patient histories, examinations, procedures, reassessments, consultations, and other aspects of the patient’s care in the electronic health record. Scribes can also search for recent pertinent information regarding specialty or emergency room visits, lab results, and radiology results to make it more accessible for the provider.
Q: Are there things a scribe cannot do?
A: Medical scribes are not licensed healthcare providers and are prohibited from interviewing patients, examining patients, assisting with medical procedures, physically assisting patients (e.g., ambulation), serving as a translator, making medical decisions, making independent observations of the patient, and signing orders.
Q: What do I need to do to prepare for having a scribe?
A: Check into any local policies for your clinic and hospital regarding non-employees. Your scribe will need a computer, a physical space to type, and access to your EHR. You will also want to think about the logistics of having a scribe in patient rooms. Will they be sitting on a stool and have a table to type? Will there be a laptop cart for them to use?
Q: Will it be difficult to adapt to using a scribe? I’ve always done my notes my way and I’m very particular about how they are written.
A: We will work with you directly to ensure that you and your scribe will work efficiently as a team. A Clinical Scribes representative will sit down with you and go over your typical patient population, logistics of your work day and work style, and your specific charting preferences. We may ask for additional information to use in training your scribe, including, but not limited to, a list of the most common visit types, common diagnoses, and any EHR templates you use. We will then train your new scribe to know your preferences well.
Q: Are the medical scribes your employees?
A: Yes, Clinical Scribes recruits, hires, trains, and schedules scribes for your practice.
Q: Who handles payroll and the associated fees and taxes?
A: Clinical Scribes.
Q: Can I reduce or increase medical scribe coverage?
A: Yes, you can request a change in medical scribe coverage. If you are looking to increase medical scribe coverage, we would like you to provide us with enough lead time to navigate scheduling changes efficiently. If you are looking to decrease medical scribe coverage, we would like you to provide advanced warning so scribes can prepare for changes in income.
Q: Do scribes do billing and coding?
A: Scribes can enter billing information into the EHR only as indicated by the provider - such as selecting a procedure code or ICD-10 - but cannot independently make a determination as to which code or billing level to select.
Q: Does the Joint Commission approve of scribes?
A: TJC neither prohibits nor supports the use of scribes (aka documentation assistants), but has published some guidelines on their website here: https://www.jointcommission.org/en/standards/standard-faqs/nursing-care-center/record-of-care-treatment-and-services-rc/000002210/
Q: How long does it take for my new scribe to start?
A: Depending on the size of the program it can vary between 1-3 months after a client agreement is signed by both parties.
Q: How are your scribes trained?
A: Scribes receive comprehensive online training that was custom-designed by and for Clinical Scribes LLC. Scribes then receive EHR training, if applicable, and subsequently spend 5-10 training shifts onsite under the guidance of a veteran medical scribe. During this onsite training period, scribes will progress from observing the medical scribe to scribing independently.
Q: How will my scribe’s note quality be monitored?
A: Our scribe managers conduct a standardized Quality Assessment of your scribe’s progress every 3 months. Based on their findings, they will discuss areas of improvement with the scribe and provide additional training if necessary.
Q: Can my scribe help with tasks other than charts?
A: Wrapping up charts can definitely involve more than documenting the visit - such as refills, phone follow-ups, late labs, etc. Your scribe can help organize and facilitate tasks like these, but CANNOT act in a medical capacity, such as interpreting the labs, calling patients with results, calling in refills, or similar. Your scribe could, however, document that you called the pharmacy, that you followed up on culture results, etc.
Q: With which EHRs do you work?
A: We work with all EHRs, and will train your scribe within the “playground” environment if available.
Q: How do you comply with HIPAA?
A: All of our scribes are trained and tested on the principles of the health insurance portability and accountability act (HIPAA) and know how to appropriately abide by these principles in the clinical setting.
Q: How will I benefit from having a scribe?
A: By having a scribe complete medical notes during patient encounters throughout the day, you will spend much less time on documentation and significantly more time with patients. Many providers find that they get home on-time more frequently, or that they can see more patients in a day.
Q: How is scribing better than dictation?
A: Having a scribe who knows your preferences well and fills out medical notes during patient encounters is quicker, more personalized, more accurate, and subsequently more efficient than using dictation methods. Since scribes document as the day progresses, there is no delay waiting for transcription.