The Joint Commission has published their position on the use of scribes and the key points from the Q&A follow:
Q. What is a scribe and how are they used?
A. A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or licensed independent practitioner (LIP). It is the Joint Commission’s stand that the scribe does not and may not act independently but documents the physician’s or LIP’s dictation and/or activities.
Q. Do the Joint Commission standards allow organizations to utilize scribes?
A. The Joint Commission neither endorses nor prohibits the use of scribes. However, if one chooses to allow the use of scribes, some of the controls the surveyors will expect to see include:
• A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities
• Orientation and training specific to the organization and role
• Competency assessment and performance evaluations
Both the scribe and physician/LIP must sign, date and time the note. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or LIP.
• Example: "Scribed for Dr. X by name of the scribe and title" with the date and time of the entry.
Q. If the unlicensed scribe enters orders into the medical record, are they considered verbal orders?
A. No. If the scribe enters orders into the medical record, they are not considered verbal orders. Verbal orders can never be given by scribes, nor given to scribes.
For more information on the use of scribes, please see the September 2010 issue of Alert.