A medical scribe benefits healthcare providers in many ways and can result in increased physician productivity and job satisfaction. This article provides a good summary of medical scribes and how they can benefit physicians and medical organizations. A table of contents makes for quick navigation within this article. More in-depth articles are available within MedicalScribes.org. These articles provide relevant summaries of the current literature from many peer reviewed journals. If you are looking to start a medical scribe program at a hospital or medical clinic then our article describing the factors to consider when starting a medical program will be of great value to you. Are you looking to convince your peers or administrators about the value of medical scribes? Then our article discussing provider efficiency and RVUs will be helpful. The article on the effects of healthcare scribes on the doctor-patient relationship will help address any concerns regarding patient care.
What is a Medical Scribe?
Medical scribes are paraprofessionals who are able to create, navigate, maintain and update electronic health records. These assistants may also be referred to as clinical scribes or healthcare scribes. Medical scribes frequently shadow a doctor during patient interactions and perform a recording role to create a complete medical record. While the field is still an emerging one, it is growing. Estimates state that there may be as many as 100,000 medical scribes by the year 2020. Scribes may work in a public health clinic, for a physician in private practice or in a hospital emergency room. This is often a gateway career, practiced by those who are pursuing further opportunities in the medical field but can be a full-time career in its own right.
Medical scribes do not work directly with patients, rather, they fall under the umbrella of health information management, and there is a lot of information to manage! This is – at least in part – due to more complex billing systems, regulations requiring documentation and reimbursement requirements from insurers. Improved patient care, however, is the central role or information management. In an increasingly digital world, the traditional paper charts that have been used by physicians in years past to record patient information are transitioning to computer files. The new method of recording patient care is through EHR or electronic health records.
Why is There a Need for a Medical Scribe?
Clinical Scribes play an important role in the medical field, especially as physicians become more and more inundated with paperwork. Estimates show that physicians – whose primary job should be direct patient care – are only spending about 30 percent of their time actually working with patients. Studies show the remaining two-thirds is spent on an ever-increasing load of paperwork.
Adequate time to evaluate and interact with a patient is necessary to provide quality health care. Doctors and patients alike find it inconvenient and trying when the physician must spend much of the visit filling out forms or entering records in front of a computer screen. This creates a negative perception among patients who may feel that their healthcare provider is not attending to the needs and concerns that brought them to the doctor in the first place. It also creates frustration for physicians who find themselves wanting to connect with patients, but are struggling to juggle patient needs and an overwhelming load of paperwork and electronic medical record keeping. Physicians who choose to focus on patients during the day often find themselves spending long evenings completing paperwork following patient-care hours. This can make patient records less accurate – particularly in emergency medicine – where doctor recollection at the end of a hectic day may be less clear and concise.
These problems, however, should not be taken to mean that electronic health records are not important. Electronic health records are hugely important in tracking and maintaining patient health and making patient care more consistent, thorough and effective over time. This is because, with EHR, information can be more easily shared among providers. What this means is that a patient’s physician, pharmacy, emergency responders and school or workplace can access the same records. In a minor situation, this simply provides better convenience and consistency; In an emergency access to information can be life-saving. The current state of EHR, however, has become cumbersome to those in direct contact with patients. Therein lies the need for medical scribes.
A Healthcare Scribe Benefits the Doctor Patient Relationship
A medical scribe allows a physician to directly interact with a patient free from the distraction of forms and notes. A well-trained scribe works in the background noting patient comments and symptoms, tests performed and coding diagnoses and treatments. Since the medical scribe is focused solely on patient records, they can do so in real time making records more thorough and accurate. By becoming a physician’s silent partner, the scribe can manage EHR freeing up the doctor for more face-to-face time. In doing so, the doctor can deliver more of the bedside manner lacking in much of modern patient care. The scribe is an expert in navigating EHR records and can help physicians prior to patient visits by quickly retrieving prior records, diagnostic results and documentation for follow-up care, continuing treatment and so on.
What Does a Medical Scribe Do?
As has been noted, a medical scribe records information at the time health care services are provided. Real-time data entry contributes specificity, clarity and accuracy in patient records. This also allows the physician – without the worry of documentation – to provide more attentive care. Scribes relieve the stress of paperwork so providers can be effective and productive in-patient interactions. The medical scribe has several duties and responsibilities. First and foremost, a scribe is not a physician and is not directly involved in patient care. He or she may not make patient-care decisions or judgments. It is the medical scribe’s duty to record information in an accurate and detailed manner exactly as directed by the physician. In addition to entering information in the EHR, the scribe may also be responsible for:
- Organizing a patient history
- Authenticating records
- Recording date, time and service provider of each patient visit
- helping a healthcare provider navigate through electronic health records
- locating, organizing and/or recording vital signs and lab results
- locating, organizing and/or recording imaging results
- noting patient or treatment progress
- Researching information contained in an EHR
- Maintaining medication listings
- Responding to office messages under the direction of the physician
The medical scribe’s role may vary from one healthcare setting to another depending on the needs of the department or practice. As this is an emerging field and the role is not as concisely defined as many within medicine. Physicians are responsible for discussing parameters of roles and duties for healthcare scribes within an individual department, clinic or practice.
Benefits of a Clinical Scribe to Doctors and Hospitals
A medical scribe plays an important role and provides many benefits not only to physicians but also to medical office staff and patients. A medical scribe becomes well-versed in terminology and coding and can reduce clerical work overall for both physician and office staff. This – in turn – can cut down the long hours needed to catch up on data entry. A medical scribe also frees up a physician’s time so that he or she can be more available to both patients and office staff. By completing these numerous clerical tasks, a clinical scribe decreases the number of distractions for a physician allowing the medical professional to be more productive during the day. With less paperwork thanks to a medical scribe, a physician has the opportunity to meaningfully interact with more patients per day. This reduces wait times, improves patient satisfaction and can increase revenue, particularly in private practice. A scribe is also beneficial in terms of completeness and accuracy of patient records because scribes update electronic health records in real time eliminating lapses in memory, distraction or confusion that can be a problem in the fast-paced, often high-stress field of medicine.
How Electronic Health Records or EHR Made Medical Scribes Necessary
EHR – or electronic health records – are far more complete, accurate and specific than the old paper charts of the past and as such contain a great deal of information to manage. Originally EHR were introduced in an effort to streamline the medical records process and reduce the amount of time health care providers spent on paperwork. These electronic medical records are the digital copies of patient records including medical charts, tests and treatment. They also contain immunization records, lab tests and radiological records as well as records of long-term care and medications. While complex, EHR can provide a very complete picture of patient health which is important to good patient care. Though EHR was meant to make physicians’ jobs easier, unfortunately, the opposite turned out to be true.
With the ability to collect more complete and accurate paperwork came an increase, rather than a decrease in the amount of information collection and this has had some unintended consequences. Physicians drowning in EHR records report lower job satisfaction and higher rates of burnout. Patients, too, are less satisfied. In short, EHR has dramatically changed the nature of physicians’ work. It has created a shift away from the amount of time spent in direct patient care and towards a more administrative position. This has made medical scribes necessary. Medical scribes specialize in retrieving, maintaining and updating documents in EHR. By delegating EHR tasks to medical scribes, physicians can get back to the business of direct patient care.
Medical Scribe Training and Education Requirements
Medical scribes are specialized paraprofessionals and as such need a specific set of skills. There are several training options for medical scribes including online courses and on-the-job training. Medical scribes who do not have clinical hours will likely start off as apprentice medical scribes until the number of clinical hours has been met. Clinical hours can vary from 50-200 depending on prior experience in the medical field, training and education.
Clinical scribes must understand and be able to use medical terminology and its abbreviations. They must know anatomy and physiology of the human body. The correct spelling of medical terms is imperative, so it is not enough to simply be familiar with the terms. Scribes should have experience with medical images and be able to use both the hardware and software related to EHR. It is also important that scribes understand and follow HIPAA and patient privacy rules. Scribes must also be aware of legal issues regarding documentation and risk management within the medical field.
After courses or on the job training, a medical scribe may be certified. To become a certified medical scribe, one must take and pass the MSCAT. MSCAT is the Medical Scribe Certification and Aptitude Test and covers terminology, anatomy and physiology, patient privacy and legal issues to ensure that prospective scribes have a solid grasp on all the relevant facets of the field.
The number of medical scribes is growing and with good reason. Complete and accurate records are a necessary piece to providing the best possible continuum of care, but attentive physicians are the other piece to the puzzle. By freeing physicians to spend less time on EHR management and more time face-to-face with patients, medical scribes become partners in strengthening the efficacy of the healthcare system overall.