A Scribe is an unlicensed position that does not and may not act independently but documents the Physician’s or licensed independent practitioner’s dictation and/or activities. Scribes may provide assistance with any or all of the clerical activities inherent to completing documentation of the patient visit. Such assistance will be under the direct oversight and control of the physician, and subject to the physician’s review and approval of actions taken to facilitate documentation and communication during patient care. The sole purpose of the Scribe position is to minimize the physicians’ clerical activities required during patient care and maximize the physician’s available time to focus on clinical requirements. The support activities provided by the Scribe under the physician’s direct oversight and control are intended to improve patient flow and satisfaction. Such activities may include:
• Transcribing for the attending physician
• Completing certain documentation requirements in an Electronic Medical Record (EMR)
• Tracking the various elements of the patient chart to notify the physician when all documentation requirements are complete.
• Facilitating the communication and coordination between the physician and other components of patient care such as tests, labs, imaging, and medical records,
• Other administrative or clerical support required by the physician.
1) Completion of the Medical Record:
• For History of Present Illness / Past Medical History / Review of Systems / Medications / Social History / Family History / Allergies / or other elements of the patient chart: The Physician, Physician Assistant or other Licensed medical provider will elicit the information as usual and Scribes will record the information in the chart for approval.
• The Scribe may accompany the Physician in the patient examination area in order to transcribe a history and physical examination as given by the patient and Physician.
• The Scribe documents in the medical chart any procedures performed by the Physician, Physician extenders, or nurses.
• The Scribe transcribes any consultations or discussions with family and/or the patient’s private physician or the on-call physician.
2) Gathering Data
• Scribes may gather laboratory results and medical records and other data for review by the physician. Data should not be entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician.
• Scribes must continuously check on the progress of this data in order to get the patient’s workup complete so that the physician is able to make treatment decisions.
• The Scribe may not provide verbal orders or relay verbal orders between the Physician and other patient care providers. For example, communicating “The doctor wants the patient to have 5 mg of morphine.” is not permissible. The Physician must communicate orders directly to other care providers.
• Scribes may communicate that orders have been written. For example “The doctor wrote orders for the patient.” or, “the discharge paperwork is on the chart.” is an allowable communication for Scribes.
• Scribes can make and answer calls for the Physician, however Scribes may not take medical data, (radiology reports, lab values, etc.) over the phone.
• Scribes may not give medical advice, communicate medical information or care plans of any kind directly with the patient or patient’s family or friends.
• Scribes can communicate waits and delays as directed by the RN or Physicians.
4) Direct Patient Care
• Scribes may not engage in any direct patient care such as direct patient contact, (e.g. lifting patients from backboard, transporting, or assisting in security issues.)
• Scribes may not assist techs in their roles of cleaning wounds, applying splints, CPR, setting up suture trays or drawing blood.
• Scribes may not bring patients food or water.
• Scribes may bring patients blankets subject to the approval of the physicians or other licensed provider.
• Scribes may not have access to narcotic prescription blanks or lock box.
• Scribes may print the depart process at the Physician’s direction.
• Scribes may not put depart paperwork on the chart without the Physician’s review.
• Scribes may not disposition patients
7) Supervisory Requirements
• Scribes will not supervise others, but may conduct scribe training.