How

 to  Utilize  a  Medical  Scribe:    

A  Guide  for  Physicians  and  Healthcare  Providers  
 
©  2008-­‐2015  Elite  Medical  Scribes,  LLC  
Minneapolis/St.  Paul,  MN  
 
 
Introduction  
 
After   four   years   of   medical   school,   3+   years   of   residency,   and   possibly   2-­‐3   more   years   of  
fellowship  –  the  last  thing  you  wanted  to  do  was  spend  your  days  performing  data  entry  or  
filling  out  paperwork.    Hopefully  the  real  reason  you  and  so  many  others  like  yourself  got  
into  medicine  was  the  humanistic  patient  connection  and  the  desire  to  help  those  in  need.  
 
The   use   of   scribes   evolved   out   of   the   need   to   reduce   or   eliminate   the   tiresome,   albeit  
necessary   bureaucratic   chore   of   documentation.     The   less   paperwork   that   a   healthcare  
provider  is  required  to  personally  perform,  the  more  time  they  will  have  for  the  patients,  
their  families,  and  the  general  task  of  actually  practicing  medicine.  
 
What  can  a  scribe  do  for  me?  
 
Most   physicians   fall   into   two   categories   when   it   comes   to   the   use   of   scribes   in   their  
profession:  “excited”  or  “cautiously  optimistic.”    There  are  many  things  that  a  scribe  will  be  
able   to   do   for   you,   however   it   is   important   to   note   that   they   are   not   replacements   for   an  
actual  physician.    (If  the  scribe  was  equally  qualified,  they’d  be  physicians,  too!)  This  is  why  
all   documentation   performed   by   a   scribe   needs   to   be   co-­‐signed   by   the   physician   (per  
JCAHO  requirements).    Nonetheless,  scribes  can  perform  much  of  the  documentation  that  is  
required  of  physicians,  and  can  be  used  to  enhance  virtually  any  medical  practice.    
 
Medical  scribes  are   versatile  and  can  perform  a  variety  of  duties  on  behalf  of  the  physician,  
depending   on   each   location   and   situation.   Most   of   these   situations   are   dependent   on   the  
amount   of   autonomy   the   physician   (and   administration)   will   allow.     When   requested,  
scribes   have   commonly   been   able   to   perform   the   following   tasks:   updating   the   physician  
when   the   workup   has   been   completed,   communication   with   other   individuals   (such   as  
nurses   and   other   department   staff)   when   the   physician   is   unavailable,   and   most  
importantly:  medical  documentation  [including  History  of  Present  Illness,  Review  of  Systems,  
family/social   history,   medical   history,   medications/allergies,   examination   findings,  
laboratory/radiology   results,   procedures,   physician   consultations,   department   course,  
assessment  and  plan,  etc.]    
Specifically,   Elite   scribes   undergo   extensive   training   to   assure   proper   billing   and   coding  
qualifications   are   met   for   the   HPI,   F/S   history,   ROS,   Phys   Exam,   MDM,   TTA   documentation,  
procedures,  and  critical  care  time.  
 
Important:  Under  no  circumstance  should  a  scribe  participate  in  any  form  of  patient  care  –
regardless  of  any  previous  experience  or  training  they  may  have.  Scribes  are  bound  by  Elite  
Medical  Scribes’  company  policy  and  by  regulations  outlined  by  the  hospital,  state,  and  
national  bodies.  Scribes  are  not  trained  or  licensed  for  any  patient  care  duties,  whatsoever.  
Scribes  are  not  trained  to  handle  body  fluids.  Scribe  are  not  trained,  boarded,  or  licensed  to  
provide  any  medical  advice  or  interpretation.  These  policies  have  been  instated  for  the  
medical  safety  of  the  patients.  They  are  inflexible  and  resolute.  Elite  Medical  Scribes  
carefully  monitors  the  endorsement  of  these  directives  by  both  the  scribe  and  the  
physician.      
 
Documentation  
 
There   are   three   basic   ways   that   a   scribe   can   enter   information   into   a   medical   chart.     These  
include   auto-­‐creation   by   the   scribe,   scribe   creation   with   physician   prompt,   and  
transcription.   These   methods   vary   in   the   degree   of   efficiency/accuracy   versus  
medical/legal   efficacy.     Each   method   has   its   advantages,   therefore   we   recommend   working  
with  your  scribe  to  use  each  of  the  three  to  your  own  personal  preference.  
 
 
 
 
  Scribe Methods of Documentation
 
  Scribe Auto- Scribe Creation with Scribe
Creation Physician Prompt Transcription
 
 
 
  Efficiency/Accuracy   Medical/Legal  Efficacy  
 
 
 
Scribe   auto-­‐creation   is   the   most   preferred   method   of   documentation   as   it   alleviates   all  
documentation   work   from   the   physician.     This   method   also   allows   for   the   most   scribe  
autonomy   and   is   the   most   accurate,   thorough   and   complete   as   it   provides   a   real-­‐time  
record   of   the   patient’s   visit.     This   type   of   documentation   is   heavily   dependent   on   the  
individual  scribe’s  abilities  and  its  development  is  the  ultimate  goal  of  Elite  Medical  Scribes.  
 
Specifically,  our  scribes  have  been  meticulously  trained  to  write  HPI’s  in  the  patient’s  own  
words,   while   “keeping   count”   of   the   number   of   HPI   elements   (according   to   billing   and  
coding   guidelines).     The   review   of   systems,   family/social   history,   medical   history,   and  
medications/allergies  are  also  easily  documented  by  the  scribe,  as  this  information  can  be  
subjectively  provided  by  the  patient  or  found  in  past  medical  records.  
Examination  findings  and  laboratory/radiology  results  are  placed  in  the  chart  as  objective  
information  (these  are  recorded  per  the  reading  of  a  qualified  attending  provider).    Scribes  
are  also  familiar  with  documenting  various  procedures  that  are  performed  by  the  physician  
and  admission/discharge  instructions.    At  higher  levels  of  training,  some  scribes  will  even  
be   able   to   help   with   documenting   assessment   and   plan   section   of   the   chart.     This   usually  
requires   a   great   deal   of   medical   knowledge   and   requires   an   experienced   scribe   that  
provider  can  be  confident  in  at  all  times.  
  
The  second  method  of  documentation,  “scribe  creation  with  physician  prompt,”  can  be  used  
when  there  is  uncertainty  on  exactly  how  something  should  be  documented,  yet  the  scribe  
remains   fully   capable   of   documenting   on   the   physician’s   behalf.     An   example   of   how   this  
would  be  used  is  as  follows:  
 
The   physician   and   scribe   leave   the   exam   room   following   a   procedure.     This   is   a   new  
procedure   with   which   the   scribe   is   unfamiliar.     The   scribe   proceeds   to   ask   the  
physician   the   important   details   that   should   be   documented.     The   physician   relates   a  
few   key   points   that   should   be   included   in   the   chart.     The   scribe   completes   the  
documentation,  which  is  later  reviewed  by  the  physician.  
 
This   method   allows   for   both   accuracy   and   scribe   autonomy,   letting   both   individuals  
perform   their   jobs   without   the   burden   of   documentation   falling   on   the   physician.     The  
“physician   prompt”   method   differs   from   transcription   in   that   the   actual   content   of   the  
document   is   not   a   verbatim   record   of   the   physician’s   thoughts,   but   an   objective  
representation   from   the   scribe’s   perspective.     Again,   as   with   all   medical   notes,   the  
document  is  reviewed  and  approved  by  the  attending  provider.  
 
The  last  method  mentioned  is  transcription.    It  is  important  to  note  that  this  should  ONLY  
be   done   in   small   amounts   and   during   certain   circumstances   where   specific   details   are   of  
the   utmost   importance.   This   would   be   required   under   rare   circumstances,   when   a   scribe  
would  otherwise  not  have  sufficient  medical  knowledge  to  accurately  describe  something.    
In  these  cases  the  physician  may  use  a  handheld  Dictaphone  to  record  a  short  paragraph  or  
two  that  the  scribe  may  then  type  into  the  medical  chart.    This  method  is  very  accurate,  but  
should   be   used   sparingly   as   it   does   not   alleviate   the   physician   from   the   task   of   creating  
documentation.    Scribes  have  much  more  training  than  transcriptionists  and  can  be  utilized  
in  many  higher  capacities.  Real-­‐time  documentation  that  is  provided  by  a  scribe  will  almost  
certainly  be  more  accurate  than  a  provider’s  recollection  after  the  fact,  but  does  come  at  the  
expense  of  objectivity.  
 
 
        Cody  Wendlandt,  MD