Admin Table of Contents
What scribes Cannot do?
A scribe cannot act independently, but simply documents the practitioner’s conversation and/or activities and relays information into the medical record.
What is a scribe allowed to do?
Scribes are responsible for capturing an accurate and detailed description of a patient encounter in the provider’s words. Scribes are clerical in nature and do not interview or have direct contact with the patient. They do not perform clinical services, administer medication, or perform treatments and procedures.
What do you think is most challenging about working as a medical scribe?
Provider verification of scribed documentation for accuracy may slow overall workflow. If the scribe is inexperienced using medical terminology and in clinical workflow, documentation errors may lead to problems such as increased costs, increased turnaround time, and billing and medical errors.
Are scribes allowed to talk to patients?
A: No. Scribes do not touch patients, handle body fluids, or provide medical advice or interpretation.
Can a scribe enter orders?
The Centers for Medicare & Medicaid Services (CMS) does not provide official guidance on the use of documentation assistance. The Joint Commission has previously defined scribes as unlicensed personnel and prohibited them from entering orders.
How can I improve my scribe?
So how do I improve my skills?
- Figure out your short hand. This can be typing down majority of the word and moving on, (i.e. cards for cardiac/cardiology, etiol for etiology, etc).
- Practice your listening and typing skills.
- Get familiar with your chart/EMR.
- Practice writing your charts!
- Don’t be afraid to ask.
How hard is it being a scribe?
This job can be very overwhelming when you first start as you are expected to complete all your charts before your shift. An average chart can range from 10-30 patients a day depending on how busy the day is.
What is a good typing speed for a scribe?
50+ WPM
Excellent verbal and written communications skills. Ability to adapt to individual site needs. Strong computer skills – technological savvy. A typing speed of 50+ WPM.
Can a nurse be a scribe?
A nurse can act in the role of a scribe, because no law prevents a registered nurse from entering orders or other information into a computer while a physician stands there and speaks the words.