Awareness : OBC Tips

Scribes:

Joint Commission Guidelines Help Regulate the Use of Scribes:

  • Verbal orders may neither be given to nor by scribes.
  • Signing (including name and title) and dating of all entries into the medical record is necessary—for both electronic or manual documentation (RC.01.01.01 and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner and other staff.

Example: “Scribed for Dr. [name of physician] by [name and title of scribe], [date and time of entry].”  The Physician must document that the note accurately reflects the work performed by him/her and authenticate it with a signature.

  • Scribes must meet all information management, HIPAA, HITECH, confidentiality, and patient rights standards, just as other hospital personnel (IM.02.01.01, IM.02.01.03, IM.02.02.01, RI.01.01.01).
  • Scribe policy must be provided to the Scribe.
  • A signed Scribe Agreement must be on file.