Page 23 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

scribes to manage a provider’s workflow while not exposing the
provider to additional risk. The scribe’s job description is unique in

that a scribe’s responsibility is to enter exactly what the provider

says during the patient encounter. If a scribe is not properly trained
or familiar with medical terminology, medications, procedures, etc.,

false or incorrect information can easily be entered into the EHR.
The scribe’s entries should be carefully reviewed before signing.

Ultimately, it is the provider who is responsible for the accuracy of
the information that is entered in the EHR.

It is possible for a provider to select a clinical assistant (non-licensed clinical
staff) who has performed clinical duties and worked with the provider to

perform the scribe services. When a scribe is also acting as a clinical
assistant during the same encounter, the scribe must log in with one set of
security rights (a clinical assistant), log out and then log back in with a

different set of rights to perform the scribe duties.
Policies and procedures must be established regarding
responsibilities, carefully managing the process/workflow, setting

clear goals and monitoring the ongoing training. The Joint

Commission has issued guidelines in the use of scribes in
healthcare organizations which can be accessed at

www.jointcommission.org.

The Responsibility of Knowing Information in

the Chart

Because of the volume of information that is contained in a single

patient’s EHR, accessing specific information from within that
medical record has been described as “trying to take a drink of

water from an open fire hydrant”. It is often information overload.
Unfortunately for healthcare providers, from a legal standpoint,

they are presumed to know the information contained within their

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