August 23, 2018
The Joint Commission (“JC”) recently released a new Standards FAQ (“FAQ”) setting forth guidelines that should be followed when physicians or other licensed independent practitioners (“LIPs”) use documentation assistants (referred to herein as “scribes”) to assist with documentation. In the FAQ, the JC recognizes that while the electronic medical record (“EMR”) holds great potential, the immediate effect of the EMR is to increase the time required for physicians and LIPs to document patient encounters and enter orders, and that physicians/practitioners are addressing this by using scribes to assist with the documentation process.
Prior to this FAQ the JC had prohibited scribes from entering orders. However, in the FAQ the JC revises its previous definition and states that it does not support or prohibit the use of scribes. The JC adopts a new definition of documentation assistant or scribe as “an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other [LIP] (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure.” The JC then sets forth minimum education/training requirements for scribes, and suggests that organizations consider the following components for purposes of defining scribes’ roles/responsibilities:
The JC also clarifies that all scribes may, at the direction of a physician or LIP, enter orders into an EMR. However, the use of repeat-backs to verify the orders is recommended. In addition, scribes who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification. The JC also explains that transcribing an order into the EMR while providing documentation assistance is not considered a verbal order.
Note, CMS does not provide official guidance on the use of scribes, although CMS has released the following that briefly address scribes: