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What You Need To Know About Unlicensed Scribes In Your Hospital

October 6, 2014

Perhaps you have noticed that when some of your medical staff visit their patients in the hospital there is another individual with them in tow. Chances are that the individual accompanying the physician is a “scribe” and that they are there to assist the physician with his or her documentation, along with navigating the medical record for relevant clinical information. While the role of the scribe today, in substance, is not very different from the role of a scribe in ancient times, the use of scribes in a regulated environment such as a hospital presents some unique risks and legal challenges that should not be ignored. Moreover, given increasing demands for more comprehensive documentation from third-party payers and the omnipresent electronic health record spurred by the CMS Meaningful Use Program, the use of scribes is likely to continue to grow. In order to avoid running afoul of legal and regulatory requirements, hospitals should be prepared to provide clear direction, by way of policies, education and auditing, to inform, guide and monitor all those involved in using or relying upon scribes in the hospital setting.

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