Medical Scribe Solutions: The Next Piece in the Healthcare Puzzle

A scribe is a medical documentation expert who works under the direct supervision of the licensed medical provider. The scribe shadows the physician into the patient room and enters patient medical data into the medical record, whether it be paper or electronic. The scribe’s medical data capture is done in real-time at the point-of-service. The medical provider is most accurate, productive and efficient when assisted documentation occurs with a scribe, as noted through Corporate Sponsor, ScribeAmerica. In contrast, the medical data capture models of medical transcription, or voice recognition software are impossible to perform contemporaneously with the physician’s H&P, and therefore, will inherently never be able to match the accuracy, productivity and efficiency of a scribe. Ask any physician who has waited on a UA, CT, or blood result, and you’ll be told that the waiting game to get data results back can drain productivity. This is another area where scribes shine, for unlike MT and voice recognition software, a scribe behaves more as a clinical information manager who actively locates patient studies, bird dogs medical tests and make calls to other departments like the lab or radiology, prepares MDM by researching PMH, can call patient’s families on your behalf, can prompt the provider for additional information or relay messages between provider, clinical staff , ancillary personnel, patients and their families. Certified medical scribes are a key facet in solving today’s healthcare challenges, and employment dilemmas, utilizing effective model and solutions through real-time partnership with clinical documentation encounters.

ACMSS is a non-profit organization representing and certifying medical scribes for gainful employment with prospective academic partners. ACMSS certifies scribes as Clinical Information Managers (CMSSs), and enables certification pathway to Certifying Academic Partners (CAPs) to academic institutions nationwide.

Contact ACMSS for more information on this growing field in high demand. Email: info@theacmss.org. Phone: 832.224.6911 or 83.ACMSS.911

Medical Transcription Lawsuit Exposes Inherent Dangers to “Care-then-Document” Model

 Article Publication:  Baldwin County jury hands down $140M settlement

This case exposes the liability of documenting after the physician patient encounter, which is the historical practice of medical transcription companies. The case also underscores the federal government’s assertion that widespread EHR use will result in a decrease in medical errors by virtue of the inherent safety measures within the EHR workflow that would have prevented this patient’s death. For example, orders do not get seen by nursing staff, let alone executed, unless they are signed by the doctor. Unfortunately, it is well known that EHRs slow doctors down, thus impeding the doctor’s ability to document in real time, which as this lawsuit implies, was a significant mistake with the hospital’s process.

Additional patient protection is afforded by the proper use of scribes since the typical scribe workflow is to document contemporaneously with the physician-patient encounter. Thus, the medical record is completed and signed by the doctor, prior to patient discharge. Proper scribe use adds another patient safety feature that, unlike doctors whose dictation may sound muffled or unintelligible by the medical transcriptionist who is listening on the other side,  doctors who work with medical scribes can be immediately queried by the scribe at the point-of-service. This dynamic dialogue is a compelling safety feature of the physician-scribe model that physicians using medical transcription, do not have.  Real time, onsite medical scribe documentation, alongside the physician, adds to increased operational productivity and patient safety protocols within the EHR environment.

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