Friday, July 13, 2012

The Joint Commission's Standards FAQ Details for the Use of Unlicensed Persons Acting as Scribes

Q. What is a scribe and how are they used?

A. 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.

Read the rest of the FAQs here.

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