Role, Function and Future of
Medical Scribes
Peter Reilly
President & CEO
American Healthcare Documentation Professionals Group
What is a Medical Scribe?
An unlicensed individual
hired to enter information into the
electronic health record (EHR) or chart
at the direction of the
physician or licensed independent practitioner.
Joint Commission
What is a Medical Scribe?
A medical scribe -- also known as a Clinical Scribe, ER Scribe, or ED Scribe -- is a
trained medical information manager who specializes in charting physician-patient
encounters in real-time during medical exams.
A medical scribe can work onsite at a hospital or clinic, or from a remote, HIPAAsecure facility. Medical scribes who work at an offsite location are known as virtual
medical scribes and normally work in clinical settings.
By handling data management tasks for physicians in real-time, free the physician to
increase patient contact time, give more thought to complex cases, better manage
patient flow through the department, and increase productivity to see more patients.
Wikipedia
Where Do You Find Scribes?
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Physician Practices
Hospitals
Emergency Departments
Long-term Care Facilities
Long-term Acute Care Hospitals
Public Health Clinics
Ambulatory Care Centers
Who Do Scribes Work For?
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Healthcare Organizations
Physicians
Licensed Independent Practitioner
Scribe Management Company (Contracted Service)
Roles & Responsibilities
• Core Responsibility:
– Capture accurate and detailed documentation of patient
encounter
• General Duties:
– Assist the provider in navigating the EHR
– Respond to various messages as directed by the provider
– Locating information for review (i.e. previous notes, reports,
test and lab results)
– Entering information into the HER as directed by the provider
– Researching information requested by the provider
Roles & Responsibilities
• What Scribes Can’t Do:
– Make independent decisions or translations while capturing
or entering information into the EHR beyond what is directed
by the provider.
– Provide any type of direct patient care.
Common Documentation Duties
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History of Present Illness
Review of Systems (ROS) & Physical Exam
Vital Signs and Lab Values
Results of Imaging Studies
Progress Notes
Continued Care Plan and Medication Lists
Benefits of Using Scribes
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Improved patient care, satisfaction, and HCAHPS scores
Improved Core Measures documentation
Keeping you up-to-date on Meaningful Use compliance issues
More thorough, detailed, and complete documentation
Greater throughput capacity
Improved physician productivity
Improved physician recruiting and retention capabilities
Reduced provider overtime expenses
Fewer patients leaving without being treated (LWOT)
Greater legal protection with real-time documentation
Greater physician workplace satisfaction
Increased Revenue; Reduced Costs
Scribe Training
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Professionalism and Etiquette
Medical Terminology
Anatomy and Physiology
Pharmacology and Diagnostic Imaging
Scribe Fundamentals
Medical Coding & Billing
Electronic Health Records
Case Presentations
Medical Charting
Scribe Certification
• The American College of Medical Scribe Specialists (ACMSS)
– Requires successful completion of a Certified Scribe Training Program
• Certified Medical Scribe Apprentice (CMSA)
– Upon graduation students passing the MSCAT qualify
• Certified Medical Scribe Specialist (CMSS)
– Once 200 hours of clinical employment experience is fulfilled
Scribe Certification
• The Medical Scribe Certification and Aptitude Test (MSCAT)
verifies skills and knowledge in these areas:
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Medical terminology and technical spelling
Basic anatomy
Basic coding
HIPAA compliance
Medico-legal risk mitigation
EHR & computer knowledge
Essential elements of documenting a provider – patient encounter
Joint Commission Accountability Measures
General knowledge of the roles and responsibilities of medical personnel
• 100 questions on the MSCAT exam
Joint Commission
• In 2011, the Joint Commission released guidelines recognizing
scribes:
– Verbal orders may neither be given to nor by scribes.
– Signing (including name and title) and dating all entries into the
medical record is necessary.
– Orientation and training must be given specific to the organization
and role.
– Competency assessment and performance evaluations should be
performed.
– If the scribe is employed by the physician, all non-employee HR
standards also apply.
– Scribes must meet all information management, HIPAA, HITECH,
confidentiality and patient rights standards as all other hospital
personnel
Dates & Statistics
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1970s – Anecdotal reports of Medical Scribe use
2003 – Commercialization of Medical Scribes is launched
2005 – First Scribe Management Company (ScribeAmerica)
2011 – 1st Online Medical Scribe Training Program (AHDPG)
2013 – The American College of Medical Scribe Specialists
Today, it is estimated that 15,000 medical scribes are in use and
growing rapidly!
Questions?
Contact Information:
Peter Reilly
President & CEO
American Healthcare Documentation Professionals Group
420 Boston Turnpike, Suite 107
Shrewsbury, MA 01545
Tel: 508.925.5400
Email: Peter.Reilly@ahdpg.com