What is a Medical Scribe

A medical scribe is someone who is trained to document physician-patient encounters quickly and accurately so that doctors do not have to. This allows doctors to spend more time face-to-face with patients and provide personalized care without getting caught up in charts. Scribes work for providers at hospitals, outpatient clinics, and medical offices to improve physician productivity and healthcare efficiency. Medical scribing was introduced in the mid-1990s, but it is still considered a relatively new idea and many people are not familiar with the concept. What is a medical scribe? This article covers what the roles and duties of a scribe are, basics of why medical scribing is effectively changing healthcare, and who might be interested in becoming a hospital scribe.

What is a Hospital Scribe?

The position varies depending on clinical setting, medical specialty, technology used, provider and workflow. Regardless of setting, a scribe’s job is to document the conversation between a doctor and patient in an electronic medical record. A medical scribe goes by many names and the title given to a scribe varies depending on whether the position is located in a hospital, clinic or office. Scribing in a hospital is common and there are many titles including:

  • Hospital scribe
  • ER scribe
  • Emergency room scribe
  • ED scribe
  • ER medical scribe
  • Emergency department scribe

There are scribe positions that can vary depending on medical specialty (e.g., ophthalmology scribe, dermatology scribe). More generic names for a medical scribe include doctor scribe, physician scribe, clinical scribe or healthcare scribe. Scribes who work remotely are often called virtual medical scribe, telescribe, virtual scribe or remote medical scribe.

Why do doctors need medical scribes?

The transition from paper charts to Electronic Health Record (EHR) systems has made it possible for doctors to deliver cohesive and quality healthcare, but it has also created a huge burden. EHRs require thorough documentation and contain dozens of checkboxes to click and unclick to ensure accuracy for insurance and billing purposes – one mistake could have many repercussions.

Some studies report that, on average, for every 1 hour a physician spends with patients, they must spend 2 hours charting those encounters in the EHR. This means that they only get to spend about one-third of their workday actually providing healthcare, while the rest is lost to documentation and other clerical duties. For this reason, many physicians tend to stop seeing patients an hour or more before their shift is over, but still end up staying late to finish charts. This results in fewer patients treated per shift, more time spent at the office, and unsigned charts piling up over several days. These undesirable effects of EHR systems have led to a significant increase in physician burnout over the past several years.

What does a medical scribe do?

Over the past few decades, medical scribes have been remedying this situation by taking over the responsibility of documentation. There are commonly two types of scribes – virtual and on-site – and a typical workday may look different for each, but they both share a common goal: to lighten the documentation load for their provider. Each shift, a scribe works one-on-one with a physician and acts almost as a personal assistant to them. The scribe is expected to stay informed regarding each patient’s status from admission to discharge and relay this information to the provider as necessary.

Documents the Patient Visit in the EHR

Scribes will often open a patient’s record prior to the encounter and inform the doctor about anything they need to know before seeing the patient. This could include things like the chief complaint, medical and surgical history, and current medications. The scribe then accompanies the physician to the patient’s bedside and watches and/or listens to the encounter. As the patient reports their history and symptoms, the scribe takes detailed notes and organizes them into descriptive yet concise HPIs. They input the review of systems and physical exam findings directly into the EHR and document the medical decision-making process as it happens. After each encounter, the provider may dictate any additional thoughts or information for the scribe to include.

Keeps Track of lab and Imaging Results

Scribes keep their provider informed about lab and imaging results and any notes added by nurses or other staff. They continue updating a patient’s chart until the patient is discharged, making any changes or additions the provider requests. They may even assist the clinic with light clerical duties as needed, such as making and answering phone calls, greeting and guiding patients, and restocking supplies. Ultimately, the scribe’s job is to make a provider’s shift as stress-free as possible.

How do medical scribes help physicians?

Clinical scribes provide financial and quality of life benefits to doctors. Since scribes chart in real-time as the physician completes their exam and discussion, patient charts can be completed and ready for review and sign-off within a few minutes of the encounter. This allows physicians to use the time that they would have spent documenting to see more patients per shift, give more attentive care to their patients, and go home from work earlier. Physicians who work with scribes are at a lower risk of burnout than those who do not. Many providers note that scribes catch details that they might have missed or forgotten. And since doctors with scribes do not need to spend time charting between patients, medical scribes also reduce wait times for patients, leading to greater patient satisfaction.

How do I become a medical scribe?

In most cases, the only requirements for becoming a scribe are a high school diploma, knowledge of medical terminology and medical workflow (which is often taught during training), a fast typing speed, and an ability to work under pressure. Anyone who has these skills may be qualified to become a scribe. However, the position is ideal for students who are pursuing a career in the healthcare field. Many pre-medical, pre-nursing, and pre-PA/NP students become scribes because it gives them exceptional clinical exposure. Scribing allows students to not just shadow providers, but to actively participate in their workday, helping students gain valuable insight into the field of work they are pursuing. Many scribes often make decisions about their career choices during their time as scribe, and have impactful experiences that they are able to write about in their personal statements.

Those who are interested in becoming medical scribes have a few options to get started. One of the most popular options is to apply for a position with a large medical scribe company. These companies serve many clinical settings in several locations. Most companies also provide paid training and will work around your classes when scheduling your shifts. Another option is to take a medical scribe course such as the one offered here at Medical Scribes Training Institute. This course provides a certificate of completion. Other options include finding a program at a college or other institution, many of which offer a certificate upon completion. Students who successfully complete these programs are trained to work as scribes and have the option of applying to locations that may not be served by scribe companies.

Medical scribes have been transforming physician workflow, increasing the efficiency of healthcare, and enabling aspiring providers to gain experience for several years. Detailed and accurate EHRs charted by diligent scribes facilitate a smooth and holistic healthcare experience for providers, staff, and patients. If you are interested in a career in healthcare and are looking to gain clinical experience, scribing may be a great place to start.