Joint Commission Guidance on Use of Medical Scribes / Documentation Assistants
The Joint Commission (TJC) recently released an FAQ describing considerations for the use of documentation assistants, more commonly referred to as scribes. TJC defines a documentation assistant or scribe as “…an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other licensed independent practitioner (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure…”
The Centers for Medicare & Medicaid Services (CMS) does not provide official guidance on the use of documentation assistance/scribes. Further, the Joint Commission does not support or prohibit the use of documentation assistants. There are no specific TJC standards that regulate the use of scribes.
However, TJC recognizes the increasing use of electronic medical records, and that the time-burdens associated with use of EMRs has increased the use of scribes in various health care settings.
According to TJC, the following should be considered when using scribes:
- Minimum competency requirements including education and training in:
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Principles of billing, coding, and reimbursement
- Electronic medical record (EMR) navigation and functionality, as appropriate based on job description
- Computerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission
- Note: The specific amount of training required in the above areas will vary depending upon the person’s past training and experience.
- Defined, documented role and responsibilities
- Documented policies and procedures for the use of scribes including but not limited to:
- Proper log-in procedures (such as prohibition of documentation assistants from using the physician or LIP’s log-in)
- Scope of documentation that may be entered
- Requirements for physician review of information and orders entered by the documentation assistant
- Order entry and submission process
- Any organizations using documentation assistance/scribes must have job descriptions that define the minimum qualifications to perform this function and the allowable scope of activities that can be performed. Job descriptions should also include:
- Competency and performance assessment processes
- Orientation, training and on-going education requirements
- Note: If an organization contracts for the services of a documentation assistant/scribe the organization must ensure that the quality of the service is the same regardless of whether it is provided directly or through a contractual agreement.
- Order Entry: According to TJC, “…all types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR.”
- The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders.
- Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification.
- Note: transcribing orders into the EMR while providing documentation assistance is not considered a verbal order. Verbal orders are different because they are expected to be acted upon immediately by individuals who are practicing within the scope of their licensure, certification, or practice in accordance with law and regulation as well as with organizational policy.
TJC is continuing to monitor this topic and the evolving use of documentation assistants/scribes. StayAlert! is monitoring this topic and will publish additional information as guidance evolves.
Included with today’s notice is an example policy as well as a sample job description, age and competency assessment.
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