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 the 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 medical decision making and diagnosis.
A Standardized Medical Chart
The benefits of Helix extends to billing and coding as well. The Helix team teaches how to craft the optimal medical chart and we worked with physicians to standardize it across the health systems where we work. The result? A medical chart with a consistent look and feel, independent of the individual scribe. Not only do the providers benefit from a standardized note, but other departments benefit as well.
"Our coders 100% prefer the scribe charts!"
- Michelle Renis, Director of Coding and Reimbursement, Medical Management Specialists
Every location is served by three levels of scribes.
The scribe core is the backbone of our operations. These scribes are college students who are on a pre-health track; pre-med, pre-PA or pre-nursing and have a strong background in medical terminology before they enter our Scribe Academy. They work on average two shifts per week.
Senior scribes mentor and train our student scribes. These full-time employees have demonstrated their mastery of the medical note, displayed professional interactions with providers, and have created and maintained excellent personal relations within our team. Seniors are tasked with working as a scribe, performing monthly audits, assisting with ongoing training, scheduling and any additional task needed from the site they are working at.
The Chief Scribe serves as the leader of the location and is charged with overall responsibility for that location. Their tasks include anything from scheduling to scribe training, or adjusting coverage and staffing to the needs of the location and much more.