What is a Medical Scribe

The medical scribe is an important asset to any medical team seeking to improve their documentation efforts.  JCAHO formally defines the role:

A medical scribe is a trained information professional who specializes in charting physician-patient encounters in real-time during medical exams. The scribe does not and may not act independently but can document the previously determined physician’s or practitioner’s dictation and/or activities.

  • Assist the practitioners listed above in navigating the EMR and in locating information such as test results and lab results

  • Prepare charting documentation for provider signature (RC.01.01.01and RC.01.02.01)

    • Scribes sign (name and title) and date their charting

    • Providers then authenticate by signing and dating  in the EMR as well

    • Scribes cannot enter provider’s date or electronic signature

Scribes must adhere to HIPAA, HITECH, confidentiality and patient rights as other hospital personnel (IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01) "Use of Unlicensed Persons Acting as Scribes".The Joint Commission. July 12, 2012.

Informally, the medical scribe is there to make providers (and others) more efficient.Their job is to handle the data entry so that the provider can focus on the patient.Having a scribe allows the provider to cognitively offload the more mundane parts of their job and focus on the medical decision making and diagnosis.