Scribes in the Hospital: A Detailed Look

Introduction

What Is  a Scribe?  A scribe is a documentation assistant.  A scribe records, in “real time,” facts and events that occur between a patient and a physician or other practitioner¹ (“Physician”) during a patient encounter.  In a hospital emergency department, the scribe accompanies the Physician to the treatment area and records in the electronic or paper medical record the results of the history and physical as they are verbalized by the examining Physician and patient.  A scribe may work with hospitalist Physicians on an inpatient unit or in a busy outpatient clinic.

Scribes may be licensed professionals, such as RNs, or they may be unlicensed individuals who are either  interested in becoming professional scribes or in getting clinical experience as they enter into other health care profession training programs.  Medical residents and medical students may serve as scribes; when they do so, they should function as mere recorders of the Physician’s dictation and not as health care providers in their own rights, interjecting their own professional thoughts and impressions.

Scribes do not act independently but document the Physician’s dictation.  This should be very clear from the record entry.  All scribe entries should include the scribe’s signature, title and the professional for whom the scribe is making entries, as well as the date and time of entry.  The Physician ultimately is responsible for all medical record documentation entered by the scribe.  Accordingly, Physicians who supervise scribes must authenticate all entries by scribes, meaning they must review, confirm, date, time and sign every entry.  The Physician should be very clear that he/she has personally performed the service described in the medical record and that he/she has verified the accuracy of the scribe’s documentation.

Under the Medicare conditions of participation and under the accreditation agency standards, unlicensed scribes are not permitted to accept, transcribe into the medical record or implement verbal orders – see below for more on this limitation.²

Why a Scribe?  By performing medical record documentation and other administrative tasks as instructed by, and on behalf of, the Physician, the well trained scribe frees up the Physician to see more patients and to spend more one-on-one time with each individual.  This improves the Physician’s and the hospital department’s productivity.  It also can contribute to a positive experience for the patient insofar as the patient may feel that he/she is getting more personalized and less distracted attention from the Physician. The time-saving aspect can be significant, particularly when a hospital is transitioning to an electronic health record where the learning curve can be high.

What Can Scribes Do?  The scribe’s major task is to take “live” dictation from the Physician and document directly into the medical record verbatim the results of the Physician-patient encounter.  Some say scribes are more valuable than mere human dictation machines because a scribe can ask a Physician for additional information when prompted to do so by an EHR.  The experienced scribe may also request clarification if the scribe believes a dictated thought is unclear or incomplete.  Scribes are employed to perform other tasks that help to increase the Physician’s and hospital department’s efficiency.  A scribe must be instructed and trained to perform delegated tasks, and the relevant hospital committee and medical staff must credential and approve the scribe for any tasks the scribe will perform.  In some settings, scribes also:

• Track and notify the Physician of patient lab values and radiology results as they become available;
• Retrieve past medical records;
• Document when consultants were paged and called back;
• Enter discharge information and instructions as dictated by the Physician; and
• Limit interruptions to the Physician’s work flow by taking dictation and performing administrative tasks within the scribe’s scope of authority.

Scribes who also are licensed health care practitioners (e.g., RNs, NPs, PAs) may be responsible for additional duties within their respective scopes of practice, privileges, skill and competency levels and experience.  For example, while an unlicensed scribe may not enter into the medical record verbal orders, an RN may do so.³  However, again, a licensed professional must be careful not to blur the distinction between the roles or to substitute his/her independent analysis or clinical judgment for the Physician’s when he/she is documenting a Physician-patient encounter in such professional’s scribe capacity.

To emphasize, unlicensed scribes are not permitted to accept, transcribe into the medical record or implement verbal orders.  Verbal order processing can only be done by a licensed, credentialed and privileged health care professional.  To clarify further, scribes may not enter Physician orders in either a paper record or EHR, even orders subject to immediate authentication by the prescribing Physician.  Scribes cannot relay verbal orders from the Physician to a nurse or other health care professional.

Legal Considerations

Medicare and Scribes.  The Medicare Conditions of Participation for Hospitals do not address the role of scribes in the hospital except in an indirect way.  The “medical records services” conditions at 42 CFR 482 .24(c) require that all patient medical record entries be “legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures.”  Further, “all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies and medical staff bylaws, rules, and regulations.”  Therefore, all scribe entries must be reviewed, confirmed and authenticated by the responsible or ordering Physician.⁴  Of note, scribe services are not separately billable to Medicare.

In an American College  of Emergency Physicians (“ACEP”) FAQ addressing CMS policies on the use of scribes, ACEP remarked on its communications with CMS officials, stating that Medicare is “not opposed to the use of personnel as scribes”; however, “there must be evidence that the practitioner reviewed and confirmed what is transcribed by the scribe.”⁵  CMS also has no objection to non-Physician practitioners using scribes to document in the medical record.

In accordance with Medicare documentation guidelines, the only information a scribe can independently document is the Review of Systems and the Past, Family/Social History components of the evaluation and management service, which can be recorded by ancillary staff or extracted from a form filled out by the patient.⁶

Scribes and “Meaningful Use” under CPOE.  Hospitals using scribes must proceed very cautiously.  The use of a scribe may jeopardize a hospital’s or Physician’s ability to achieve “meaningful use” under the Medicare/Medicaid electronic health record (“EHR”) incentive programs.  To maintain eligibility for the EHR incentive payments, unlicensed scribes should not be permitted to enter orders into the EHR.

The American Recovery and Reinvestment Act of 2009  (“ARRA”) established the Medicare and Medicaid EHR incentive programs providing for payments to eligible professionals, eligible hospitals and critical access hospitals to adopt, implement or demonstrate meaningful use of certified EHR technology.  One of the criteria for achieving meaningful use and thus getting the incentive and later not being penalized under Medicare/Medicaid, is the use of computerized provider order entry (“CPOE”).  The ARRA  regulations establishing what is required to become a meaningful user will, in 2014 and beyond, require that CPOE for medication, laboratory and radiology orders be directly entered by any licensed health care professional who can enter orders into the medical record per state, local and professional guidelines.  CMS has issued additional guidance to clarify this requirement, which provides that “any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order” in the calculation of CPOE usage for purposes of achieving meaningful use.  This guidance continued by providing that the credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.  In conversations with CMS, Hall Render has learned that CMS is looking for independent, third-party credentialing, such as that provided by professional groups or trade associations.

The primary concern with the use of scribes is that: (1) scribes often are not licensed health care professionals as is required to achieve “meaningful use” under CPOE; and (2) the certified EHRs are required to utilize clinical decision support that will present warnings of drug interactions, etc., when orders are entered.  CMS has expressed its concerns that entry by a non-qualified clinician, such as a scribe, will jeopardize the efficacy of these warnings.

Failure to achieve meaningful use can be a significant financial harm to hospitals and Physicians in that they may lose their Medicare and/or Medicaid incentive payments, which can be several million dollars for hospitals and approximately $50,000 for Physicians.  Additionally, Medicare reimbursement through reduction of the market basket adjustment for hospitals and percentage reductions in the Physician fee schedule will be imposed for failure to achieve meaningful use beginning in FY 2015 for hospitals and CY 2015 for Physicians.

Scribes and State Law.  Hospitals wishing to use scribes must consult state law.  For example, the Indiana Hospital Licensure Rules specifically state that “all entries in the medical record shall be made only by individuals given this right as specified in hospital and medical staff policies.”  Therefore, an Indiana hospital wishing to use scribes would have to prepare and periodically update appropriate policies addressing the use of scribes.⁷

Accreditations Standard Considerations

The Joint Commission (“TJC”).  In a July 12, 2012 FAQ addressing the subject of unlicensed scribes in the hospital setting, TJC stated it neither “endorse[d] nor prohibit[ed] the use of scribes,” but if the hospital chose to permit the use of scribes, TJC surveyors would expect to see compliance with the Human Resources, Information Management, Leadership (contracted services standard) and Rights and Responsibilities of the individual standards.  The specific standards identified in the FAQ are set forth here.

For example, surveyors would expect to see:

• A job description that recognizes the scribe’s unlicensed status and clearly defines the scribe’s qualifications and job responsibilities;
• Scribe orientation and training, competency assessment and performance evaluation;
• The scribe’s compliance with HIPAA, confidentiality and patient rights standards;
• Performance improvement review that ensures scribes are not acting outside the scope of the job description; and
• Proper authentication of all scribe entries:
  • Signature stamps are not permitted with scribe entries;
  • Authentication must occur before the Physician and scribe leave the patient care area; and
  • Authentication cannot be delegated to another Physician.

With respect to the issue of scribe order entry, TJC specifically states it “does not support scribes being utilized to enter orders for Physicians or practitioners due to the additional risk added to the process.”  The concern is that if scribes are permitted to enter orders into the medical record, there is the possibility that an order could be carried out before it is properly authenticated by the Physician.

American Osteopathic Association Health Facilities Accreditation Program (“HFAP”).  HFAP has no standards specifically addressing the use of scribes.  However, HFAP’s standards interpretation staff offered the following guidelines on use of scribes in the hospital setting:

• The scribe’s role must be clearly defined in accordance with state law and regulations.  The scribe job description must clearly outline the scribe’s responsibilities and duties, including the scribe’s qualifications and “scope of practice.”  The scribe’s orientation and training must be documented as well.
• Non-licensed scribes cannot accept or enter Physician orders into the medical record.  Both the scribe and the hospital’s Physicians must clearly understand this limitation.  Further, the scribe cannot relay orders to a nurse or other health care professional.  However, if RNs, NPs, PAs or licensed senior medical residents are used as scribes, these professionals may accept and implement Physician orders in accordance with state law, scope of practice guidelines and hospital policy.
• All medical record documentation must be reviewed, dated, timed and signed by the attending Physician.
• The medical staff, allied health and nursing staff must be educated on the scribe’s role and responsibilities.  The hospital must monitor how scribes are used to ensure that no orders are being given to, or implemented by, scribes.  During an HFAP survey, the surveyors will review medical records and orders to ensure that scribes are being used properly.⁸

Practical Takeaways

Scribes are frequently requested by hospital Physicians, particularly those working in emergency departments and in busy ambulatory clinics.  They are viewed by hospital administrators as big Physician satisfiers and as one possible path to improved productivity – if the scribes are well trained and integrated with department Physicians and staff.  Hospitals interested in using scribes should make sure that the guidelines and accreditation standards summarized here are followed so as not to risk an accreditation survey deficiency or loss of EHR incentive payments.  Also, it is imperative that scribes are skilled and can navigate the hospital’s EHR effectively.  Otherwise, the Physician will end up having to backtrack to correct the medical record entries, thereby negating the benefit of having used a scribe.

If you have any questions or would like additional information about this topic, please contact Adele Merenstein at 317-752-4427 or amerenst@hallrender.com, Jeffrey W. Short  at 317-977-1413 or jshort@hallrender.com or your regular Hall Render attorney.

¹ “Other practitioner” could include an advanced practice registered nurse, physician assistant or licensed independent practitioner.
² Scribe FAQs found here.  (last visited on May 21, 2013).
³ Sachin Patel MD, MPH; Afsha Rais, MS and Alan Kumar, MD,  Focus On: The Use of Scribes in the Emergency Department found here.  (last visited May 21, 2013).
⁴ For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author and the authentication methods permitted include a handwritten or electronic signature.  Generally, stamped signatures are not acceptable with certain exceptions.  On May 17, 2013, CMS published Transmittal 465, which articulates an additional new exception to the general rule  that signature stamps cannot be used to authenticate a medical record entry.  For more information on Transmittal 465, which becomes effective on June 18, 2013, please refer to the upcoming Hall Render Health Law News article on this topic (pending).
⁵ American College of Emergency Physicians Scribe Frequently Asked Questions, FAQ #3  found here.  (last visited on May 29, 2013).
⁶ Id.
⁷ 410 IAC 15-1.5-4(e)(2).
⁸ Information addressing Use of Scribes in an HFAP Hospital, Personal E-mail from HFAP Standards Interpretation Staff (info@hfap.org), May 14, 2013.