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 licensed independent practitioner (APRNs are considered licensed independent practitioners in some states, Physician Assistants are not considered licensed independent practitioners). It is the Joint Commission’s stand that the scribe does not and may not act independently but documents the physician’s or licensed independent practitioner’s dictation and/or activities.
Scribes also assist the physician or licensed independent practitioner 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 follow the physician or licensed independent practitioner and record information into the medical record, with the goal of allowing the physician or licensed independent 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 licensed independent practitioner or be a contracted service.
Q. Do the Joint Commission standards allow organizations to utilize scribes?
A. The Joint Commission does not endorse nor prohibit the use of scribes. However, if your organization chooses to allow the use of scribes the surveyors will expect to see:
Compliance with all of the Human Resources (including contracted services if contracted), Information Management and Rights and Responsibilities of the Individual standards including but not limited to:
- A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05)
- Orientation and training specific to the organization and role (HR.01.04.01, HR.01.05.03)
- Competency assessment and performance evaluations (HR.01.06.01, HR.01.07.01)
- If the scribe is employed by the physician all non-employee HR standards also apply (HR.01.02.05 EP 7, HR.01.07.01 EP 5)
- If the scribe is provided through a contract then the contract standard also applies (LD.04.03.09)
- Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as do other hospital personnel (IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01)
Compliance with the Record of Care and Provision of Care standards also apply and include but are not limited to:
- Signing (including name and title), dating of all entries into the medical record—electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff.
- Example: “Scribed for Dr. X by name of the scribe and title” with the date and time of the entry
- The physician or licensed independent practitioner must authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician. (RC.01.01.01 and RC.01.02.01)
- Although allowed in other situations, a physician signature stamp is not permitted for use in the authentication of “scribed” entries-- the physician must actually sign or authenticate through the clinical information system. (RC.01.02.01).
- The authentication must take place before the physician and scribe leave the patient care area. (RC.01.02.01 and RC.01.03.01)
- Authentication cannot be delegated to another physician or licensed independent practitioner.
- If the organization determines that the scribe will be allowed to enter orders into the medical record, those orders entered into the medical record cannot be acted on until authenticated by the specific physician/licensed independent practitioner who provided the orders scribed. Authentication includes the physician signature (electronic or manual) and the date and time (for deemed status purposes). (RC.01.02.01, and PC.02.01.03)
- The organization implements a performance improvement process to ensure that the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being acted on before they are authenticated. (RC.01.04.01)
Q. If the unlicensed scribe enters orders into the medical record are they considered verbal orders?
A. No. If the scribe enters orders into the medical record they are not considered verbal orders.
The Joint Commission considers verbal orders to be those orders given by the physician or licensed independent practitioner to a licensed person such as the registered nurse or registered pharmacist who is authorized by organization policy to receive and record verbal orders in accordance with law and regulation. Verbal orders must then be read-back to confirm accuracy (RC.02.03.07). Under these circumstances verbal orders can be acted on before authentication by the prescribing physician is received.
Verbal orders can never be given by scribes. Verbal orders can never be given to scribes.