The ultimate goal of the healthcare industry is to improve the health of individuals and communities through high-quality care services. Medical scribes contribute to this goal by becoming the eyes and ears of physicians, noting vital details of patient and physician interaction accurately and constantly.
As an integral part of the healthcare ecosystem, the role of medical scribes is projected to grow by 23% by the year 2028. This growth projection highlights the increasing importance of the diverse responsibilities of a medical scribe, and our blog is here to take you through these responsibilities.
What is a medical scribe?
The role of a medical scribe was born out of the necessity to navigate the complexities of modern medicine, particularly the transition to electronic health records.
This technological shift led to a surge in documentation and clinical duties for physicians, often at the expense of their focus on patient care. As a result, hospitals across the US, now employ 100,000 scribes, providing much-needed relief to overburdened physicians.
Therefore, one can define medical scribes as the personal assistants of physicians who take responsibility for documenting everything in the EHR. This allows the physicians to concentrate on their patients, ensuring they receive the best care.
The Growing Role of Medical Scribes in Modern Healthcare
Medical scribes are transforming how healthcare works today, and the significance of their work cannot be overlooked, as their ulterior goal is better healthcare for everyone.
Here are some of the benefits of medical scribes that are making their presence felt in modern healthcare.
- Scribes reduce the errors in documenting medical records, which is vital for patient safety.
- When scribes work with physicians managing notes and records, the work runs smoothly.
- As physicians get more time with patients, they can provide clearer explanations of diagnoses, respond to patient inquiries in a timely manner, and provide better follow-up treatment plans.
Key Responsibilities of Medical Scribe
The main responsibilities of a medical scribe revolve around documenting patient history, family history, and past medical histories; taking down dictated radiographic impressions; and any other information pertaining to patients’ encounters in the emergency department. The following section will help you have deeper, in-depth knowledge about the medical scribes’ key responsibilities.
They are as follows:
Real-Time Documentation during Patient Encounters
Real-time scribing is possible through patient encounters, where a scriber is available virtually or in person to document every important thing. This process confirms that the clinical notes are completely updated, leaving no more additional administrative work for providers after the appointments.
Here are a few of the advantages of real-time documentation.
- The Real-time presence of the scribes ensures patients trust the physicians more and improve the patient’s experience.
- Real-time documentation reduces the likelihood of errors and missing information.
- Scribes can move on to the next task without a delay, as during real-time documentation work gets done right at the moment.
- Lastly, the real-time documentation is also in alignment with the HIPAA guidelines and CMS guidelines as the scribers are trained professionals.
Updating Electronic Health Records (EHRs)
- The Electronic health record is a digital collection of the patient’s health record, which is stored and accessed electronically.
- EHR management skills are very important skills for scribes. They need adequate acumen to understand the system input and update information that is accurate, accessible, and organized.
- Medical scribes should have the ability to properly transcribe the medical terminologies during patient encounters.
Here are a few advantages of properly updated electronic health records:
- 38% of physicians have adopted EHR when work is properly updated in the electronic health record; it reduces paperwork and reduces duplicate testing, contributing to better workflow.
- It simplifies the access to patients’ histories, hence streamlining accurate and better care coordination.
Assisting with Charting and Medical Coding
The medical scribe’s job demands high levels of attention to detail, as medical coders later work with the same information. For example, they will translate healthcare services, i.e., procedures, diagnosis, and treatment, into proper codes.
While doing this particular job, coders have to be in alignment with (the American Academy of Professional Coders), which really standardizes systems like the Healthcare Common Procedure coding system and International Classification of Diseases (ICD) to ensure correct coding.
Go through the table below to understand how a proficient medical scriber will simplify the work of medical coding.
Reviewing and Organizing Clinical Data
During any time of the day, physicians might review the notes, discuss the adjustments required, and prepare for the remaining appointment.
When medical scribes are wrapping up their work by the end of the day, they are required to review all the documents. Additionally, the physician’s insights should be taken when any notes and orders have to be finalized. This review and organization of clinical data ensures that records are up-to-date, which can contribute to reducing physicians’ burnout rate by 27%.
Ensuring Accuracy and Compliance
Maintaining accuracy and compliance is one of the key responsibilities of the medical scribes: to obliterate errors in the coding and billing process, adhere to the HIPAA regulations, and adhere to the patient records. Overall, when medical scribes are in alignment with regulatory compliances, they avoid penalties of legal issues and deliver high-quality patient care.
Supporting Physicians with Administrative Tasks
As mentioned earlier, physicians are swamped with work, and an extra pair of hands to support physicians with a little bit of administrative work is not a bad idea.
Below, we have listed two administrative tasks scribes handle apart from updating EHR, and they are as follows.
- Forms and paperwork: Medical scribes take care of the paperwork, i.e., preparing referral letters, managing medical documents, and completing forms.
- Clerical task: Scribes also undertake clerical jobs such as making referrals, ordering lab tests, and scheduling appointments.
Medical Scribe Workflow: A Day in the Life
The job of a medical scribe has evolved beyond simple note-taking, as to a great extent, it supports clinical decision support.
Pre-Visit Preparation
The medical scribes arrive a few minutes before the physicians in different settings and specialties (hospitals/clinics of orthopedic or oncology, etc.). Then, they review the patient’s schedule and begin to prep the chart by collecting past medical information.
During the Patient Encounter
- Once the respective physician is here, they start seeing patients. During this time, the scribe usually stands or sits beside the physician and documents the discussion between the patient and the physician.
- Medical Scribes with proper training will be able to accumulate the information in a professional medical manner.
- If the physical test is involved in the process, physicians will verbalize or share the information. This is also where medical scribes need to have a very good knowledge of the medical terminology to note down every piece of information physicians share with them.
Post-Visit Documentation & Review
Once the medical scribe can complete making the notes for the physicians, they get it reviewed by the physicians. Scribes are also responsible for creating discharge summaries and printing them out for the patients. Medical scribes keep repeating this work so that physicians stay productive throughout the day.
Skills and Qualification Medical Scribe Require
Medical scribes responsibilities can only be accomplished once they have honed the following skills and qualifications.
Medical Terminology Knowledge
- Medical scribes working closely with healthcare professionals and physicians need to be properly aware of anatomy terms, medical terms, procedures, diagnostic codes, procedures, and more.
- Additionally, to grow in the medical scribe career, it is of supreme importance to have quick learning ability. Should adapt to clinical settings quickly and understand the roles and writing in the clinical setting.
Attention to Detail
- If the medical scribes don’t pay attention to detail the minor mistakes can have huge consequences. As the repercussions can be high, medical scribes have to do a good job documenting patients’ physical exam findings, treatment plans, medical history, and ongoing patient encounters.
- Medical scribes should work on their time management skills. They have to be very present in the moment as they are taking down notes; they also need to converse with the professional whenever required.
- Maintaining everything while meeting several patients on a regular basis, understanding their concerns, and then documenting them simultaneously, processing the information, and moving on to the next task.
Tech Savvy and EHR Proficiency
- Most of the data is stored in computers these days, so it is the major reason the medical scribe must be comfortable working with advanced technology and data entry ability.
- One of the most important responsibilities of a scribe is to get all the recordings in real-time on electronic health records (EHR). So, anyone aspiring to be a medical scribe should adopt adequate knowledge about how to work with an electronic health record.
Communication and Confidentiality
- A Medical scribe’s job demands communication with physicians, all types of medical professionals, and patients. Precisely why they need good command over their writing skills, but at the same time, proficient in verbal communication.
- All information the patient has communicated should be confidential. The Medical scribe’s work should always be aligned with the HIPAA regulation, which entails that every piece of information the healthcare organization has collected is sensitive to disclosure until they have patients’ consent.
Given the fact that the medical scribe plays an essential role in the industry, we have mentioned some of the crucial skills they must need to have to do the job well. But there are few other skill set that comes without saying, such as empathy and compassion, critical thinking, teamwork and collaborative efforts, and ability to multitask.
Lastly, to become a scribe, it is essential to have at least a high school diploma and plan or pursue a course in anatomy, biology, and physiology.
Settings Where Medical Scribes Work
Medical scribes can be found in numerous kinds of work settings as they are vital partners of physicians.
Hospital and Emergency Room
- When scribes are working in the emergency room, they work as extra pairs of hands for physicians, retrieving test results and facilitating communication between the health care providers.
- As medical scribes are the bridge for healthcare communication, important messages, and facilitating collaborations, this helps streamline the workflow in a high-pressure scenario.
Outpatients Clinics
- Outpatient scribes help out physicians in private practices and clinics. Their work revolves around the doctors. However, they don’t need to work in the emergency room.
- The pace of work is much slower than in the emergency room, helping scribes to gradually build rapport with doctors and patients.
- The work hours for outpatient clinics are more consistent; they are usually regular business hours.
Telemedicine and Virtual Scribing
- Virtual scribes can be available for the emergency rooms as well as for outpatient clinics. The only difference in this scenario is they document the interaction with the patients virtually.
- Telemedicine is one scenario where the role of the scribe is very important as it is a fast-paced work environment. The healthcare provider has to quickly get used to the different patients and virtual scribes. Quickly documenting the interaction simplifies the accuracy and efficiency of the telemedicine interaction.
The Impact of Medical Scribes on Healthcare Efficiency
The responsibilities of a medical scribe contribute to healthcare efficiency in the following ways:
Reducing Physician Burnout
Physician burnout levels are alarmingly high compared to any other professional working in any other profession, majorly due to administrative overload and long work hours. Scribes can reduce this burnout level by saving up to 100 minutes from their longer than 8-hour shift. Helping physicians focus on their passion- that is, caring for the patients and enhancing the work-life balance.
Improving Patient Care Quality
57% of the patients mentioned that doctors spend less time on the computer when assisted by scribes, helping patients have higher satisfaction levels. When patients have access to better services, it helps in fostering better trust and loyalty.
Enhancing Workflow and Time Management
Medical scribes improve work efficiency by improving real-time documentation, managing electronic health care records, and data entry, leading to faster patient encounters, lower administrative burdens, and much more efficient workflow.
Medical Scribes vs. AI Scribes: What’s Changing?
First, let’s understand AI scribes. Artificial intelligence medical scribes are futuristic software solutions that enhance accuracy and efficiency in documenting patients’ encounters with physicians. When compared to a human scribe, it can process a vast amount of information and generate comprehensive notes in real-time.
Human Scribes: Strengths and Limitations:
- Human scribes are more proficient in capturing the subtle details (context and nuances) of the patients.
- Quickly spot inconsistency and get it rectified on the spot. It is possible that humans have a better contextual understanding and can interpret complex medical terminologies better.
- Shadow physician’s documentation style to offer tailored support.
While these technologies do make the medical scribe look like a feasible option, there are potential drawbacks. Medical scribes require a monthly salary, and their annual cost ranges from $32,000 to $42,000. On top of that, they need to be regularly trained in the latest medical technologies.
Lastly, they come along with operational limitations, fixed schedules, breaks, potential sick days, and turnover.
AI-Powered Scribes: Benefits and Risks
- AI scribes have the ability to convert language into text at the very moment, reducing the time taken between consultation and documentation.
- Traditional scribes require a lot of training to switch their work from one specialty to another. In contrast, AI scribes can adapt to any specialty or a specific physician according to the individual preference of the physician.
- The impact on physicians’ productivity due to AI scribes is huge, as they free up physicians’ time even more than traditional scribes.
- AI scribes are also cost-effective as the expense only revolves around occasional updates and maintenance.
These four scenarios clearly portray the fact that AI scribes are better than traditional human scribes, but being completely dependent on an AI scribe may not be beneficial as it might not always lead to positive consequences. Despite these promising capabilities, one major concern of working with AI scribes is the loss of human touch while dealing with patients.
Hybrid Models: The Future of Medical Documentation
The best way to approach the scenario is to combine the work of human and AI scribes, as both can complement each other capabilities. AI scribes can augment the capabilities of healthcare professionals, and human scribes can take care of critical thinking and interpersonal skills.
Conclusion
Whether you choose to work with an AI scribe combined with a medical scribe is completely an independent decision of your healthcare establishment.
But we hope the blog has helped you understand the key responsibilities of medical scribes: documenting, updating EHR, charting and medical coding, reviewing, maintaining compliance, and more, that help them become an unsung hero of your organization as they play crucial roles in improving the workflow, allowing physicians to focus all their energy on patient checkups rather than paperwork.
It’s time to enhance your workflow by adding a medical scribe to your team!
What are the core duties of a medical scribe?
Here is the list of core duties of a medical scribe, which every medical scribe is expected to be skilled in and perform on a regular basis.
- Real-time accurate documentation of accurate health records.
- Document accurate patient history and medical examination.
- Print lab reports and prepare charts for the new patients.
- Communicate with nurses, physicians, and healthcare professionals on a regular basis.
- Review and organize the documentation by the end of the day for accuracy and completeness.
Do medical scribes need medical training?
No. Medical scribes are expected to have a high school diploma. However, healthcare establishments prefer hiring medical scribes who possess basic knowledge of human anatomy and medical terminology.
How do scribes help doctors?
One of the most significant ways medical scribes contribute to the healthcare system is by reducing doctors’ documentation burden and simplifying the workflow of patient-physician interaction.
Can AI replace human medical scribes?
The idea of AI replacing human scribes is not impossible, however it is a little far-fetched. As in the present moment, AI has its limitations, such as possible threats of data breaches and expensive software updates, which can have negative consequences, and the best incorporated AI scribe is along with medical scribes.
