It's a gorgeous weekend, and you are playing a game of basketball with friends. You take a jump shot, scoring two points, but twist your right ankle on landing. You feel immediate pain and stop playing. After resting for an hour, you notice increased swelling and are having difficulty walking, so you go to the nearby urgent care center. The physician comes to see you, introduces herself, then introduces the medical scribe, who moves to the corner of the room in front of the computer. As the doctor starts asking you questions, the scribe begins typing.
Scribes are becoming increasingly common in doctor's offices. But what do they do, what type of training do they have, and why are they gaining in popularity?
What are medical scribes?
Scribes are assistants to physicians and other healthcare providers. Their roles include entering electronic documentation (notes) into the computer, including patient history, physician examination findings, test results, and other information pertinent to your care. While the scribe's primary role is to enter medical documentation, they may also check for test results and assist with assigning diagnoses and billing. The physician is then responsible for carefully reviewing the scribe's notes, correcting any misinformation or omissions, and signing the notes.
Scribes are often college students or recent college graduates seeking additional exposure to the healthcare field before applying to medical school or other graduate training programs; however, scribing can also be a full-time career. They receive training on how to document as well as on medical coding and billing rules. In general, scribes do not have healthcare provider training or certification. Unless your scribe is also a nurse, medical assistant, or other certified medical professional, they should not be providing medical advice or delivering care to you.
Scribes are members of the healthcare delivery team, and are therefore accountable to all applicable institutional policies and are expected to act professionally. For example, scribes are held to the same standards to protect patient privacy as other health care professionals. Scribes should be introduced to the patient when they enter the room. If you are uncomfortable with a scribe being present during your visit, you should request to be seen by the healthcare provider privately.
Why are scribes gaining popularity?
The practice of medicine requires a large number of administrative tasks, including thorough documentation of all patient visits. As the majority of U.S. hospitals and physician offices have now transitioned to electronic documentation, physicians are spending an increasing amount of time on the computer instead of with the patient.
Adding a scribe to the team enables physicians to spend more time directly talking with patients, while the scribe documents the visit. Scribes are being used in all care settings, including the primary care office, specialist offices, urgent care, emergency departments, and inpatient hospitals. A recent study in the primary care setting found reductions in the amount of time spent with electronic documentation and improvements in physician productivity and work satisfaction associated with the use of medical scribes.
The future of scribes
Today, scribes typically accompany the physician and patient in the room. In-person scribes are also being supplemented by virtual scribes, where the scribe is not physically present in the room with the patient. For example, physicians may use a recording device to capture their interview and examination of the patient. The electronic recording can then be sent to the scribes (who are offsite), and then transcribed and entered into the computer. Newer video teleconferencing software and smart glasses are also being used to allow the scribe to view and transcribe the visit into the computer from an offsite location. The latter technology has the benefit of allowing the scribe to work in real time, asking clarifying questions to the providers, and entering the notes faster. Importantly, with both these scenarios, physicians are still responsible for the content of the notes and must review and sign off on the notes.
The U.S. Centers for Medicaid and Medicare Services, which oversees federal health insurance programs, is currently working to reduce documentation requirements for billing, which may help decrease physician workload. In addition, advances in technology may one day completely automate documentation of patient visits.
In the meantime, scribes provide the ability for physicians to focus more on the patient relationship and interaction and less on computer data entry.
(Adam Landman, M.D., M.S., M.I.S., M.H.S., is a contributor to Harvard Health Publishing.)