Page 25 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Documentation via Scribe

With an increasing documentation burden, some practices have
begun using scribes as a cost-effective and efficient way to help

providers spend more time focused on patients. A scribe is an
extension of the provider, and it takes time and effort to train

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 and workflow, setting clear
goals, and monitoring the ongoing training. In April 2020, 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.

5 https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-
treatment-and-services-rc/000002210/

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