Medical Scribes

paxnerospaxneros
in CDI Talk Archive
As of late we have noticed the increase in Medical Scribe usage with our physicians. The increase has me intrigued. With the increase of the EMR in facilities many physicians are turning to Scribes to take the "busy-work" of order entry and electronic progress notes out of their hands. This allows them to see more patients instead of bogging down in the clerical duties of the EMR. There is now specialized training and certification for this new profession.

What if you have a Certified Medical Scribe who is also a Certified Documentation Specialist? And if you threw in some E/M knowledge - I would think you would have a highly marketable professional!

Early in our program we actually had a physician who wanted his own personal CDS to round with him on his patients. We declined at the time. :) Now I'm wondering if he may have been onto something!

Have any of you had experience within your facilities using Scribes? Have you been asked to educate them in Documentation Improvement?

Norma T. Brunson, RHIA, CDIP, CCDS

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    In our facility, I often feel that out NP's and PA's are functioning as scribes (unfortunately). As far as I know, we do not actually have any "scribes" yet. Great concept though. I can see how this could be an area that would blend nicely with a CDI/S background.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • cstukenbergcstukenberg
    edited May 2016
    What is the certification for the scribe and who is Certifying it?



  • laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
    edited May 2016
    I would think this might be questionable with having a CDS combined with a Certified Medical Scribe. Would there be a legal issue with the person in charge of clarifying records being the person doing the documenting in the actual record? Just a thought.

    Laura Bohls, RN CDS
    Prairie Lakes Healthcare System

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    In my mind, the Scribe would be a certified CDS (CCDS) but would not be employed by the hospital as a CDS. I think that Norma was suggesting that this area could potentially be a job opportunity for a CDS.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • Unknown
    edited May 2016
    I did a quick online check. A scribe is someone who is a high school graduate, has aspirations for furthering their education in the medical field, get paid minimum wage during training with a 20% wage increase after the scribe course. Their job duty is to follow the physician and type their notes for them. Must be a good typist with excellent spelling.




    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources
    Menorah Medical Center



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, my understanding is that currently Scribes are generally college students that are majoring in a health-care related field. Obviously this job description would not work for a CDS now, as the compensation would be ridiculously low. However, I can see with the changes in HC, there may be a time where the financial incentive to improve documentation (and thus reimbursement) may actually be sufficient to make this type of thing possible. We also tend to get a lot of questions from MD's about how to improve their documentation to ensure a higher reimbursement and unfortunately because I don't have experience in outpatient/clinic billing, I don't feel like I can help much. I can see how someone with that experience (even an experienced outpatient/physician coder without a CDS background), may be very helpful in this type of position.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • kshumpertkshumpert
    edited May 2016
    We are going to be using scribes, however we have decided that the basic requirements are not sufficient. One physician's scribe is a chiropractor here.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela




  • cstukenbergcstukenberg
    edited May 2016
    Is there a certification out there for this? Or how do you define or decide if competent or would it be similar to transcription competency?

  • vdavis2vdavis2
    edited May 2016
    We have scribes in our ER... Your online check was correct! They scribe literally follows the doc around and transcribes their exact words. They are even there during the physical assessments taking notes as the MD reports off their findings... It is interesting. My Dad was in the ER the other day and the Scribe just smiled and wrote down notes. The MD has to review, addendum, and sign everything off. It does take a little getting used to but the one in my Dad's room was so sweet she so just seemed like another friendly face. :)

    Vicki Davis
    vdavis2@armc.com

  • paxnerospaxneros
    edited May 2016

    I agree Katy, our Mid Levels are often used in this position as well. We
    have provided some light documentation education for these folks as they the
    ones primarily documenting within the records. Especially the ones who work
    w/our hospitalist group.

    Norma t. Brunson, RHIA,CDIP, CODS,

  • paxnerospaxneros
    edited May 2016

    I've seen varying salary ranges for this position - anywhere from $24K to
    $54K. I would imagine- as it happened w/ CDI- the more skill-sets and
    experience you bring to the position the more $$ could be seen for the
    profession.

    Norma T. Brunson,RHIA, CDIP,CCDS

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