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Scribes for the EHR

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Last Post by wwalecka 9 years ago

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Anonymous

(@Anonymous)

Posts: 0

New Member Guest

Topic starter

Is anyone out there using scribes to go in with your providers? Are you Jacho accredited and how do they recieve this practice of scribes? What have been your pros and cons?

Posted : May 23, 2013 2:51 am

eglopez

(@eglopez)

Posts: 37

Eminent Member

We're FHQC clinic and we're thinking of getting scribes. The con to it is that it would be medical students from the local college and will come and go; training can take its toll when I'm the only one doing it for the clinic.

A local private family practice clinic use scribes, not all providers utilize them. I've asked them and they said that the documentation is 'faster' but they still have to take the time review the note. They also get students from the local college who are in medical school and those who were transcriptionists or MA or LPN. That clinic is not JCAHO accredited.

Posted : June 26, 2013 3:27 am

Conda

(@crobinson)

Posts: 255

Reputable Member

We are a multi specialty clinic and have 3 of our providers using scribes and are jayco accredited. We use both MA's and LPN's. Our providers like it because they have more interaction face to face with the patients. We have the scribes on laptops in the room while the providers are on thin clients. Both are in the chart at the same time and can document at the same time as long as both are signed in as the provider and not in the same form at the same time. The encounter can be reviewed as they go and signed off at the end of the visit.

Posted : June 26, 2013 8:40 pm

RSBojalad

(@rsbojalad)

Posts: 47

Trusted Member

What are the scribes allowed to enter in the Chart. I was informed Jacho does not allow scribes to enter orders. Is that an issue? Do you run into any issues with the provider & scribe being in the encounter at the same time?

Posted : July 1, 2013 3:01 am

cisaac

(@cisaac)

Posts: 33

Trusted Member

We have just hired our first scribe, is anyone willing to share best practices for setting up security and how do you handle their login on each item they enter for the provider? (for E&M guidelines, the provider must obtain the HPI, how to you prove this if using a scribe?)

Posted : July 14, 2013 6:20 am

aroberts

(@aroberts)

Posts: 176

Reputable Member

We are an orthopaedic practice that has used scribes/court reporters even prior to EMR. I was a scribe until recently moved to our IT department and would be willing to talk with you. I will tell you at the start of the morning, our physician logs the laptop in as himself and gives the computer to the scribe. They enter the information as instructed, including orders per the physician. We also have a disclaimer at the end of each note that has the scribe information. I am not sure JCAHO but we typically use athletic trainers or MAs for our scribing.

Below is a sample of our disclaimer. We are also planning on giving a presentation at CHUG in Vegas regarding scribes.

Good luck and feel free to contact me if you want to discuss more: [email protected]

Amy Roberts, Kansas City Bone & Joint Clinic

I attest that I performed the duties of a scribe for this encounter, in the presence of the dictating physician. Amy Roberts, M.S, ATC/L

I attest that I performed all the work during this encounter and that the scribe only recorded my findings. John Doe, M.D.

Posted : December 26, 2013 1:33 am

wwalecka

(@wwalecka)

Posts: 40

Trusted Member

I would like to know about security for scribes as well. I am struggling at finding how to limit the ability to SEND orders unless I push for the Pending Approval prescribing method or keeping Signed Clinical List Changes unchecked.

Isn't there a concern about auditing if the scribe is signed in under the provider??? I still think that is asking for trouble and orders get sent inadvertently.

Regards,

WendyWalecka, MS, RN
Affinity and Ministry Health System
Ascension Information Systems
PH: (920) 628-9423

Posted : November 27, 2015 9:53 am

wwalecka

(@wwalecka)

Posts: 40

Trusted Member

I also would like to know this.

Wendy Walecka, MS, RN
Affinity and Ministry Health System
Ascension Information Systems
Ph: (920) 628-9423

Posted : November 27, 2015 9:55 am

wwalecka

(@wwalecka)

Posts: 40

Trusted Member

I can see using CMA/RMAs or LPNs as they are at least credentialed. What I am struggling with is the legality of using a scribe who is NOT credentialed and how do you limit actually entering/signing off orders without the provider logging in and the scribe working under the provider's log in. I have an issue with no audit being available.

Wendy Walecka, MS, RN
Affinity and Ministry Health System
Ascension Information Systems
Ph: (920) 628-9423

Posted : November 27, 2015 9:58 am

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