Page 26 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

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. There must be strict adherence

to that tenet. A scribe is prohibited from adding, deleting, editing or

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

the EHR. Policies and procedures must be established regarding

responsibilities, carefully managing the process/workflow, setting

clear goals and monitoring the ongoing training. In August 2018,

the Joint Commission updated its FAQ on the use of scribes in
healthcare organizations.
5

Thorough Documentation

While the medical record should be your first line of defense

against a medical malpractice suit, many claims are lacking in one

or more areas of documentation, making cases more difficult to

defend.

In short, it is well established that the following elements comprise
the foundation of minimal documentation standards. Conduct a

thorough physical exam and personally obtain a complete history

of the patient and document the findings. At a minimum, document

5 https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1809&StandardsF
AQChapterId=13&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=scribe

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