Scribes in the Hospital Setting

PUBLISHED: May 29, 2018
Relevant to: Critical Access Hospitals, Hospitals

A recent Joint Commission blog post describes the development and implementation of a novel medical scribe program in a hospital setting that was presented in the May 2018 issue of The Joint Commission Journal on Quality and Patient Safety. The scribe program at Hennepin County Medical Center, Minneapolis resulted in significant improvements in areas such as clinician satisfaction, time for documentation, ability to listen to patients and provide high-quality care and completing EHR documentation during the workday, rather than at home.

When implementing a scribe program, hospitals will want to consider the following best practices:

  • The physician/provider is ultimately responsible for the content of documentation/medical record.
  • Each note recorded by a scribe should be signed by the scribe and must be authenticated by the physician/provider.
  • Scribe notations should clearly indicate that the scribe is recording while the physician/provider is performing the service.

TJC is currently reviewing the use of scribes in healthcare settings and here are no specific TJC standards that address the use of scribes in the healthcare setting. However, organizations wishing to implement the use of scribes should ensure that their program complies with:

  • TJC RC.01.01.01 which requires organizations to maintain complete and accurate clinical records.
  • TJC RC.01.02.01 which requires organizations to ensure medical records are authenticated.

The Centers for Medicare and Medicaid Services (CMS) guidance regarding signature requirements when scribe services are used by a physician/non-physician practitioner became effective in June 2017 and includes the following:

  • “Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided.”
  • Physicians/non-physician practitioners using scribes should make certain they sign and date the documentation.

While CMS does not require a scribe to sign/date documentation, best practice indicates it is, in fact, a good idea to require said signature/date. At this time, until there is further guidance from TJC, hospitals should consider requiring their scribes to sign/date their documentations. Such actions allow hospitals to conduct audits, more effective quality improvement programs and assure competence and accountability of the individuals who are scribing.

Included with today’s notice is a link to the CMS guidance as well as an example policy for the use of scribes in the hospital setting.

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