Should You Hire a Medical Scribe?

Patient interaction is an important part of office visits—perhaps even the most important part. But with the implementation of electronic health records (EHR) and the increased documentation required for medical coding, physicians must figure out how to interact with their patients while also recording detailed, accurate information during the exam.

Rather than split their focus, some physicians are choosing to bring on a new team member—a medical scribe.

Wondering whether hiring a medical scribe makes sense for your practice? Here’s a quick overview of the role, as well as some of the benefits, challenges, and best practices.

Role and Responsibilities
According to The Joint Commission, a medical scribe is “an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant).”

A scribe accompanies the physician or licensed provider into the exam room and captures documentation of the health provider’s encounter with the patient in real time. The scribe’s notes could include the history of the patient’s present illness, details of the physical examination, vital signs, medication lists, and more. The information must be accurate, detailed, and recorded in a timely manner.

It’s also important that the involvement of a scribe is noted in the records. When scribes record information, they log in to the EHR with their own security rights and must include the name of the provider, date and time of the visit, and authentication in the note. However, the provider is still responsible for the contents of the note, so the physician or licensed practitioner must review it, verify the accuracy of the information, and authenticate it as well—before leaving the exam room.

Scribes may also assist the provider in navigating the EHR and locating information such as lab results for review, but they can’t act independently, don’t have direct contact with the patient, or perform any clinical duties.

The work of a scribe can bring many benefits to your practice’s workflow. By employing a scribe, you’ll be free to focus on your patients and give them your full attention. The hands-on, face-to-face care they’ll receive will likely boost patient satisfaction—as well as your own job satisfaction. You’ll also reduce your clerical workload, improving your overall efficiency and productivity. And the comprehensive, real-time documentation could help your practice meet meaningful use requirements, quality standards, and billing compliance.

Of course, the addition of a new team member also brings changes and challenges. The physicians’ verification and authentication of the scribed documentation adds another step to the patient exam process, which could slow down the overall workflow. Inexperienced scribes may make errors as they learn the medical terminology and technology, resulting in increased costs, wasted time, and billing issues. And there are legal considerations, as well as payer requirements to consider. Finally, for some patients, the presence of another person in the exam room may cause them to be less forthcoming about their personal medical concerns, which could impact their diagnosis and treatment—and ultimately, their quality of care.

Best practices
If you choose to hire a medical scribe, follow these three best practices for a greater chance of success:

1. Set goals. Measure the practice’s overall improvement in efficiency and productivity by setting goals and tracking progress. Your goals could be to increase revenue, enhance patient satisfaction, boost provider productivity, or improve the timeliness or quality of documentation. Not sure if the cost of a scribe is worth it? To evaluate the effectiveness of using a scribe, Medical Economics recommends using objective metrics, such as “relative value units per hour or shift, number of patients seen per hour, clinical versus administrative time, average charge per billable visit, and patient satisfaction survey results.”

2. Communicate with patients. The presence of a scribe can be a new and somewhat unsettling experience for many patients. To put a patient’s mind at ease, you should begin the exam by explaining how a medical scribe will allow him or her to receive more focused attention from you, the physician. Some patients may feel uncomfortable discussing a particular medical issue with you because a scribe is in the exam room. So beforehand, you and the scribe should come up with a subtle signal you can use to direct the scribe to leave the room.

3. Stay engaged. Although using a scribe will free you from many clerical duties, you’ll still need to be involved with patient information. Your review and authentication of the scribe’s documentation ensures that your patients’ records are accurate and complete.

If you’re looking to decrease your clerical tasks and increase your patient interaction, consider hiring a medical scribe to help you achieve those goals. Weigh the pros and cons, and if you decide to move forward with the hire, put best practices in place to ensure that you, your patients, and your practice see positive results.


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