Medical scribes work at documenting medical provider dictation and activities, allowing providers to spend more time with patients, according to an article published in Medical Economics.

Medical scribes can accurately document physician or independent practitioner dictation and activities, allowing providers to spend more time with patients. Maxine Lewis, president of Medical Coding & Reimbursement in Cincinnati, discusses the role of scribes in medical practices.

Lewis notes that medical scribes are unlicensed, trained medical information managers, who specialize in charting physician-patient encounters during medical examinations, and work either onsite or from a remote facility. The information recorded by the scribe is entered into the electronic health record or chart, at the direction of the physician or independent practitioner. Scribes allow for accurate documentation, while enabling the provider to spend more time with the patient. The scribe only documents the physician’s or practitioner’s dictation and activities, and may not act independently. Scribes can provide assistance in navigating the electronic health record and locate test or laboratory results and other information. They can also support workflow and documentation for coding of medical records.

“There are several ways to determine the effectiveness of a scribe program using objective metrics,” Lewis writes. “They include relative value units per hour or shift, number of patients seen per hour or shift, clinical versus administrative time, average charge per billable visit, number of incomplete and deficient charts, door-to-discharge time, and patient satisfaction survey results.”

What are the duties of a scribe and are they beneficial to a medical practice?

A medical Scribe is an unlicensed, trained medical information manager specializing in charting physician-patient encounters in real-time during medical exams. A scribe can work onsite at a hospital or clinic, or from a remote, HIPAA-secure facility. A scribe enters information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner. The use of a scribe allows the provider to spend more time with the patient while ensuring accurate documentation. The scribe may not act independently but documents the physician’s or licensed independent practitioner’s dictation and activities.

Scribes also assist the physician or licensed independent practitioner in navigating the EHR and locating information such as test and lab results. They can support workflow and documentation for medical record coding.

Potential scribe duties

  • Transcribing details of the physical exam and patient orders. This includes any lab tests, imaging tests, or medications ordered by the physician. A scribe may also be present to record a physician’s consultations with family members or other physicians about a specific patient’s case.
  • Documenting procedures performed by the physician or any other healthcare professional, including nurses and physician assistants.
  • Checking the progress of and reviewing lab, X-ray and other patient evaluation data for comparison, and transcribing the results into patient charts so that a patient’s workup is complete and the physician can make sound treatment decisions.
  • Recording physician-dictated diagnoses, prescriptions, and instructions for patient discharge and follow-up.
  • Recording a provider’s consultations with other healthcare professionals, patients, and family members.

Medical scribe qualifications

Scribes should have a number of skills to adequately perform the job. Some of those skills include:

  • knowledge of medical terminology;
  • recognition of the physical exam process and ability to record exam details;
  • computer proficiency and ability to quickly learn new applications;
  • legible handwriting and ability to accurately record information.;
  • organizational skills with focus on tracking patient care and improving patient flow;
  • professional demeanor and recognition of privacy considerations for patients and families; and
  • the ability to multitask and act calmly in busy or stressful situations.

Training for the Job provides the fundamentals for training for this invaluable healthcare skill. Available training includes “Medical Terminology, Medical Transcription, Medical Coding and Billing, and Medical Office Protocol.”