Documentation Assistance Provided By Scribes

What guidelines should be followed when physicians or other licensed independent practitioners use scribes to assist with documentation?

Any examples are for illustrative purposes only.

The complexity and pace of medical practice have increased greatly over the last few decades. At the same time, financial constraints have increased the pressure on physicians and other licensed independent practitioners (LIPs) to see more patients in less time. Yet the most dramatic change in practice for many physicians and LIPs has been the introduction of electronic medical records (EMRs).

While EMRs hold great potential as tools for improving the quality, safety, and coordination of care, the most immediate effect has been to increase the time required for documentation and order entry. To address the burden of using an EMR for routine recording of history and physical examination findings, retrieval of laboratory and radiography results, and order entry, many physicians, LIPs, and health care organizations have begun to involve various health care professionals in assisting physicians and LIPs with documentation.

Based on the request of stakeholders, The Joint Commission reviewed the literature and conducted learning visits at two organizations to understand different models for providing documentation assistance. The goal for these activities was to identify potential quality and safety issues regarding current practices of documentation assistance. The Centers for Medicare & Medicaid Services (CMS) does not provide official guidance on the use of documentation assistance.

The Joint Commission has previously defined scribes as unlicensed personnel and prohibited them from entering orders. However, due to the emergence of models including both licensed and unlicensed personnel of varying levels of skill and clinical knowledge, that previous definition is no longer valid or appropriate. There are individuals with the official title of “scribe” for whom documentation assistance is their only role, and there are individuals who perform dual roles that include clinical responsibilities as well as documentation assistance.
 
The Joint Commission does not support or prohibit the use of documentation assistants.
Quality and Safety
During its research, The Joint Commission identified the following potential quality and safety issues:
• Unqualified staff performing documentation assistance
• Unclear role and responsibilities when providing documentation assistance
• Documentation assistants using the physician log-in rather than independently logging in to the EMR
• Failure of physician or LIP to verify orders or other documentation entered during clinical encounter

Based on the recent efforts to better understand the evolution of this role and its different models, The Joint Commission provides the following guidance:
Definition: A documentation assistant or scribe may be an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other licensed independent practitioner (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure.

Competency: At a minimum, all persons performing documentation assistance have the education or training on the following:
• Medical terminology
• Health Insurance Portability and Accountability Act of 1996 (HIPAA) 
• Principles of billing, coding, and reimbursement
• Electronic medical record (EMR) navigation and functionality, as appropriate based on job description
• Computerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission

The amount of training required in these areas will vary depending upon the person’s past training and experience.
Role/Responsibilities—In addition, organizations should consider the following components to ensure clarity regarding role and responsibilities:

Policy and procedure: Each organization should develop a policy/procedure regarding processes associated with personnel providing documentation assistance. Policies may include proper log-in procedures (such as prohibition of documentation assistants from using the physician or LIP’s log-in), the scope of documentation that may be entered, requirements for physician review of information and orders entered by the documentation assistant, and the order entry and submission process.

 Job description: All organizations utilizing personnel to provide documentation assistance must have job descriptions that define the minimum qualifications to perform this function and the allowable scope of activities that can be performed. Job descriptions should also specify plans to periodically assess performance and continued competence.
• Orientation and ongoing training and education to the role must be provided.
• Organizations that contract for the services of a documentation assistant must ensure that the quality of the service is the same regardless of whether it is provided directly or through a contractual agreement. At a minimum, the organization should ensure the scribe meets all of the same competency and training described above.

Orders:  All types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders.  Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification.

Transcribing orders into the EMR while providing documentation assistance is not considered a verbal order. Verbal orders are different because they are expected to be acted upon immediately by individuals who are practicing within the scope of their licensure, certification, or practice in accordance with law and regulation as well as with organizational policy.

The Joint Commission will continue to monitor the evolving use of documentation assistants in the field and recommends that organizations consult available resources for guidance.

Suggested Resources
• CMS meaningful use requirements including FAQ Number 2851, Transmittal 751, and the CMS website
• American College of Medical Scribe Specialists (ACMSS)
• American Health Information Management Association (AHIMA)

This information was published in the Perspectives® Newsletter, August 2018, Volume 38, Issue 8 - The Official Newsletter of The Joint Commission.
Last updated on April 16, 2020
Manual: Nursing Care Center
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