Let’s Talk About…Certified Medical Scribe Specialists (CMSS)

What is the background of a medical scribe?

Scribes have been around since the biblical times and continue to exist as recorders of medical events. The primary function of a scribe is the creation and maintenance of the patient’s medical record, which is created under the supervision of the attending physician or mid-level providers. The scribe documents the patient’s history and story through direct observation of the clinician’s interaction with the patient as well as the procedures performed, the results of laboratory studies, and other ancillary information gathered at the point of care.  Scribes document the work product of the provider-patient encounter, thus allowing providers to spend more time on direct patient care.

What are current scribing trends and models?

Medical scribes are deployed across the healthcare spectrum, originating in emergency departments, now being deployed steadily into hospitals and outpatient facilities.  Medical scribes provide real time supportive services to medical providers by documenting clinical patient encounters into the electronic health record and at the point of service under direct supervision of the provider. They serve as a right hand to physicians, or mid-level providers, capturing the care encounter while also coordinating the presentation of diagnostic data to assist the clinician with clinical decision‐making.

What is a Certified Academic Partner?

Certified Academic Partners (CAPs) are academic institutions that train and certify medical scribes in partnership with ACMSS toward educating and filling the scribing role. CAPs offer an education-to-certification pathway toward certification and credentialing as a Certified Medical Scribe Specialist (CMSS).  The demand for scribes has traditionally been filled with eager pre‐medical students, learning first‐hand about the workflow patterns and patient care they will deliver in the future. CAPs enroll a variety of students, both clinical and non-clinical in nature.  A medical scribe’s role is focused on creating comprehensive medical records,  therefore, unburdening the medical provider so more time can be spent on direct patient care.  The base education has been set around medical scenarios, case management, disease processes, medical terminology, anatomy, physiology, E/M levels, fundamentals of EHR, and regulation compliance. Scribes are pre‐screened for the selection process.

What are the skill set requirements and training required to become a medical scribe?

Medical scribes may be trained onsite through a scribe program or through affordable online distance education programs through ACMSS Certified Academic Partners (CAPs). Skill sets include strong English grammar, a compelling interest in healthcare and patient improvement, a strong desire to work in a clinical setting, superior analytical and resource skills, understanding and training in enabling technologies (with computer and keyboarding skills), an understanding of information workflow, attention to detail, keen listening skills, and strong multi‐tasking abilities. A scribe, by design, is a self‐starter who works efficiently in a variety of different settings and paces and follows directions well. The medical scribe is the physician’s assistant and is continuously utilizing a strategic thought process. The individual also has a desire to work within a team of allied healthcare personnel. Together the physician and the scribe partner to create a comprehensive and meaningful care encounter record. Scribes are also expected to be well‐versed in HIPAA and regulatory compliance.  Medical scribes have a steep learning curve, with clinical shadowing required, in the post-training phase.

How does medical scribing connect to the broader documentation spectrum?

Medical scribes are a central liaison within any healthcare facility, outpatient clinic, surgery center, hospital, or emergency department. They uniquely interact and collaborate with other members of the healthcare team, tracking patient information, to include ancillary departments of laboratory and radiology units. Medical scribes adapt to technological needs of the facility, understand the basis of electronic medical record systems, coding practices and levels, medical decision‐making, and the disposition of the patient. Medical scribes fill a need identified by market demands. Clinicians focus on the patient, documentation is tracked and delivered in real time, and documentation is available at the point of care – as defined by our healthcare system.

Could this be a stepping stone for medical transcriptionists? Is this an alternate career path?

There are similarities and distinct differences between medical transcriptionist and medical scribes, as are there in comparing these roles with any other health information management role. Just as medical scribes would need additional training to transition to the unique application of a traditional transcription skill, with some additional training in specialized applications, medical transcriptionists would also be uniquely qualified to fill the roles open in the emerging and growing field of scribes. Different paces, sizes, and styles of healthcare facilities, be it rural or urban, offer career transitioning options.

One thing is certain. National mandates and incentives will increase the adoption of electronic medical records. Healthcare will need professionals who have a flexible resume of contributory skills applicable to an EHR‐centric documentation setting. Scribing is a potential alternate documentation setting for medical transcriptionists and other allied healthcare fields.  Continuing education is imperative for the well‐being of the allied healthcare system.  Medical scribes will continue to adapt, evolve, and innovate alongside clinicians to achieve sustainable solutions in the US Healthcare System.

How does my academic institution become a Certified Academic Partner?

Interested academic institutions may contact ACMSS at info@theacmss.org for review and assistance in meeting prospective outcome and goals.  Cost is $250/annually and creates an education-to-certification partnership and pathway toward preparing students to sit for MSCAT national certification and credentialing exam. Supplemental Medical Scribe Training Guides and HIPAA for Scribes are available in the Store to compliment both new and transitioning programs core curriculum.

How do I become a credentialed and Certified Medical Scribe Specialist (CMSS)?

First and foremost is educational training, either offered through our Certified Academic Partners or through accredited scribe training programs.  Prospective medical scribes ready to sit for the national exam, Medical Scribe Certification & Aptitude Test (MSCAT).  All related exam material and preparation guides may be found in the Store.  Content covers pre-clinical and clinical training.

In order to sit for the MSCAT, the scribe must have successfully completed 200 hours of clinical instruction. However, those individuals possessing a certification or licensure of Practical Nurse, Registered Nurse, Paramedic or Certified Medical Assistant will be allowed to sit for the exam after having successfully completing 50 hours of clinical instruction.

Successful pass of the board exam of 80% or higher is minimum standard.  Certification examination contains 100 questions based on medical terminology, HIPAA, medicolegal risk mitigation, visit-level assignments, knowledge of computer skills and function of an electronic health record. All topics are covered in pre-clinical and clinical training.  Exam consists of multiple choice, multiple-multiple, true-false, and fill-in questions.  Members of ACMSS are allotted 3 attempts toward successful pass. Additional questions may be directed to: certifications@theacmss.org.

Does ACMSS allow volunteers on committees?
Yes, this may be accessed here.