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Last week I went to see a consulting cardiologist who introduced herself with "Hi, I'm Dr. ---- and this is my medical scribe." I had never met a medical scribe in person, but I was favorably impressed. A medical scribe helps your visit go more smoothly.

Medical records, also known as "paperwork" pronounced with a sigh of frustration, have been the bane of doctors, who have to write or dictate them, and all kinds of other health professionals, who have to read them, for generations. The advent of medical scribes, however, is changing the way doctors keep their records.

The Evolution Of Patient Record Keeping

Before about 1980 in the United States, and even today in many countries, doctors recorded their observations and orders in longhand in the patient's medical chart. Notorious for illegible handwriting, doctors often could not read even their own notes, and errors in medication, treatment, retention, and discharge were commonplace. By the 1980's, most doctors had started dictating their records. The doctor simply spoke into a recording device and hours, or days, or occasionally weeks later, a medical records transcriptionist transformed the doctor's dictation into a written record. 
 
 
Medical transcription was also not without its drawbacks. Some doctors have accents or mumble, causing inexperienced transcriptionists to misinterpret their words. Doctors still had to review transcripts before they became an official part of the record, relying on memory and clinical judgment to guess what they had said when they could not remember what they had said. More than an exercise in typing, medical transcription also depended (and depends) on the good judgment of the transcriptionist to interpret ambiguous tape recordings in ways that make sense, without entering the medical decision making process.
 
Over the last five years, medical record keeping has evolved even more in the USA. Doctors and clinics are given incentives by the Affordable Care Act to create electronic records that can follow a patient anywhere in the world, instantly communicated to other doctors as they need them. 
 
Some doctors actually switched over the paperless record keeping 10 years ago, but others still struggle to check the right boxes on the "easier" pad computer system. Entering the office now is the medical scribe.

What Is A Medical Scribe?

The position of medical scribe is not really a twenty-first century innovation. A few doctors have used medical scribes in lieu of transcriptionists since the 1970's. However, the widespread employment of medical scribes has occurred only in the five years since the passage of the Affordable Care Act.
 
A medical scribe is an unlicensed person authorized to enter information about a patient visit into the electronic health record or  medical chart. The scribe records interactions between the patient and the licensed practitioner, whether a doctor, a nurse practitioner, or physician assistant. 
 
A medical scribe is only authorized to document the interaction between doctor and patient. The scribe does not comment on treatment or engage the patient in any way (although typically the scribe is introduced to the patient as a matter of being polite) The difference between a medical scribe and a medical transcriptionist is that the medical scribe takes notes in real time, as the examination is being conducted, and the record of the visit is recorded by the time the visit is complete.
Continue reading after recommendations

  • Hixon JR. Scribe system works like a charm in Sarasota ED. Emerg Dept News. 1981. 3:4.
  • The Joint Commission. Use of Unlicensed Persons Acting as Scribes. http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?StandardsFAQId_426&StandardsFAQChapterId_66. Accessed 14 July 2015.
  • Photo courtesy of ursonate via Flickr: www.flickr.com/photos/ursonate/6784296439
  • Photo courtesy of Bev Goodwin via Flickr: www.flickr.com/photos/bevgoodwin/8837556274

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