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A medical scribe -- also known as a Clinical Scribe, ER Scribe, or ED Scribe -- is a trained medical information manager who specializes in charting physician-patient encounters in real-time during medical exams. A medical scribe can work onsite at a hospital or clinic, or from a remote, HIPAA-secure facility. Medical scribes who work at an offsite location are known as virtual medical scribes and normally work in clinical settings.
A medical scribe's primary duties are to follow a physicians through his or her work day and chart patient encounters in real-time using a medical office's Electronic Health Record and existing templates. Medical scribes also generate referral letters for physicians, manage and sort medical documents within the EHR system, and assist with e-prescribing. Medical scribes can be thought of as data care managers, enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours. Medical scribes, by handling data management tasks for physicians in real-time, free the physician to increase patient contact time, give more thought to complex cases, better manage patient flow through the department, and increase productivity to see more patients.
The Joint Commission released guidelines for the use of medical scribes July 2012. The Joint Commission's guidelines explained: "A 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). It is the Joint Commission’s stand that the scribe does not and may not act independently but can document the previously determined physician’s or practitioner’s dictation and/or activities. Scribes also assist the practitioners listed above in navigating the EMR and in locating information such as test results and lab results. They can support work flow and documentation for medical record coding. Scribes are used most frequently, but not exclusively, in emergency departments where they accompany the physician or practitioner and record information into the medical record, with the goal of allowing the physician or practitioner to spend more time with the patient and have accurate documentation. Scribes are sometimes used in other areas of the hospital or ambulatory facility. They can be employed by the healthcare organization, the physician or practitioner or be a contracted service." The American Health Information Management Association also published guidance in its November 2012 edition of Journal of AHIMA for physicians on the use of medical scribes, echoing and elaborating on The Joint Commission's guidance by explaining that "a scribe can be found in multiple settings including physician practices, hospitals, emergency departments, long-term care facilities, long-term acute care hospitals, public health clinics, and ambulatory care centers. They can be employed by a healthcare organization, physician, licensed independent practitioner, or work as a contracted service."
An increasing body of research has shown the use of medical scribes is associated with improved overall physician productivity, cost- and time-savings, and patient satisfaction. An in-depth study conducted by The Vancouver Clinic in Vancouver, WA from 2011-2012 found that medical scribes improved the quality of clinical documentation and allowed doctors to see extra patients, while noting the risks associated with scribe turnover and doctors' unfamiliarity with the scribe concept. Notably, research has recommended that healthcare providers employ medical scribes to reduce time spent performing data entry and other administrative tasks, which can increase physician fatigue and dissatisfaction.