Certificate in Medical Scribe
Mona M. Burke, RHIA, FAHIMA
A person trained in health information management techniques as they relate to data entry and structure of the electronic health record is a medical scribe. A medical scribe works in "real time" with the clinical practitioners (commonly the physician provider) to enter the data obtained through observation and calculation throughout the face-to-face patient encounter. The data entry screens differ according to vendor for the electronic health record platform, but follow a template "point and click" system for most required elements of medical reporting, such as history and physical exams, progress notes, and e-prescribing. The general benefit and objective of the medical scribe position is to eliminate the time necessary for the physician to enter this information into the data collection system him/herself, and therefore increase patient contact time during the encounter.
The need for more detailed documentation in health care has expanded the time necessary to capture that information, thus necessitating health care providers to use medical scribes to provide the technical support required to document the encounter. A medical scribe:
- Assists the provider in navigating the electronic health record
- Responds to requests and messages from the provider using the electronic health record
- Locates information for review from previous notes, tests and laboratory results, etc.,
- Enters information into the health record as directed by the provider
- Researches information requested by the provider
The role of the scribe may differ dependent upon the provider and the health care setting. Scribes can be found in multiple settings including physician practices, hospitals, emergency departments, long term care facilities, public health clinics and ambulatory care centers. They can be employed by the health care organization, physician, practitioner or may work as a contracted service.