![]() Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification.ĭata is scarce about how scribes might affect productivity. ![]() The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Orders: All types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR. Job descriptions should also specify plans to periodically assess performance and continued competence. Job description: All organizations utilizing personnel to provide documentation assistance must have job descriptions that define the minimum qualifications to perform this function and the allowable scope of activities that can be performed. Policies may include proper log-in procedures (such as prohibition of documentation assistants from using the physician or LIP’s log-in), the scope of documentation that may be entered, requirements for physician review of information and orders entered by the documentation assistant, and the order entry and submission process. ![]() Policies and procedures: Each organization should develop a policy/procedure regarding processes associated with personnel providing documentation assistance. TJC says that clarity regarding roles and responsibilities of a scribe should consider the following: The amount of training will be dependent on a person’s experience and skills. Principles of billing, coding, and reimbursementĮlectronic medical record (EMR) navigation and functionality, as appropriate based on job descriptionĬomputerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission Health Insurance Portability and Accountability Act of 1996 (HIPAA) TJC also updated its definition of a scribe to say that “A documentation assistant or scribe may be an unlicensed, certified (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance…consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure.”Īt a minimum, TJC noted that all persons performing documentation assistance have education or training on the following: ![]() Unclear role and responsibilities when providing documentation assistanceĭocumentation assistants using the physician log-in rather than independently logging in to the EMRįailure of physicians or licensed independent practitioners (LIPs) to verify orders or other documentation entered during clinical encounter Unqualified staff performing documentation assistance The Joint Commission (TJC) released updated information2 in April 2020 about using scribes that identified the following potential quality and safety issues: Is a scribe a possible fix for documentation tasks? What should you consider before hiring a scribe? Is there a risk of introducing a scribe into the physician-patient experience? The average physician in an outpatient setting spends 1–2 hours an evening finishing their medical records.1 This has led providers to look for new ways to decrease EHR frustration and improve patient interactions, while still maintaining personal satisfaction. By COPIC’s Patient Safety and Risk Management Department ![]()
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