Medical Scribe Vs Clinical Assistant

Are you thinking about using one of your assistants as a medical scribe?

The primary responsibility of the medical scribe is to accurately document information in real-time. Scribes cannot work independently or document any information other than what is specifically told to them by the provider.  In addition, all documentation from the scribe is reviewed and verified by the doctor. The scribe has several duties including, but not limited to, physician guided documentation inside the EHR and assisting the provider in navigating the EHR to find information such as lab values and test results.

Some offices have attempted to expand the roles of their clinical assistant to include scribing duties, however this is not recommended and is often unsuccessful. The main reason this is not recommended is due to security rights. Since the scribe is providing the physician’s documentation inside the EHR, their security access to the chart is almost identical to that of the physician. On the other hand, clinical assistants have a different security access within the EHR and their documentation is done independently, without being reviewed by the physician. Therefore, in order for a clinical assistant to also act as a scribe, they must have two separate log-ins with different security rights for each role. This leads to a lot of wasted time and resources as the assistant will have to constantly log in and out of the two different accounts when  switching from clinical assistant to scribe documentation. In order to prevent these types of issues and to achieve the most benefit from the scribe, most offices are choosing to have a scribe who only acts in that role.

 

AHIMA. “Using Medical Scribes in a Physician Practice” Journal of AHIMA 83, no.11 (November 2012): 64-69 [expanded online version].

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