Wednesday, March 13, 2013
The Use of Scribes for Clinical documentation
Given the rigors of documentation required for Meaningful Use, quality measurement, and ICD10, some organizations are adding dedicated scribes to rounding and evaluation teams.
I was recently asked two questions about scribes.
Does Meaningful Use allow the use of scribes?
Meaningful Use does not specify who does the documentation, as long as the thresholds for data capture are exceeded.
What are the best practices for scribes used at BIDMC?
At BIDMC the ED scribes use their own credentials and create a "scribe note" under their own identity.
When the physician goes to chart, they have the option to import the scribe note into their own note.
This has 3 important benefits:
1) The scribe is never given access to the system with the physician's credentials (as I've heard happens with some scribe arrangements)
2) The physician has the option to import and then writes/edits the note as they wish (ie - they retain full control for the contents of the note)
3) The MD actively uses the computer and the scribe does not come between the physician and system. (In some arrangements the scribe acts as a human UI to the system and the MD only interacts with the scribe. This becomes a barrier to many of the benefits of online clinical decision support).
Although future improvements in clinical documentation may eliminate the need for scribes, there are best practices that minimize privacy risks and "cut/paste" documentation challenges.
Posted by John Halamka at 3:00 AM