Proper Use of Scribes
According to The Joint Commission and the Centers for Medicaid and Medicare Services scribes are allowed to perform the following duties and tasks:
- Documentation of the History of Present Illness, Review of Systems, Past Medical History, Physical Examination, Results, Procedures, Physician Consults, Medical Decision Making and Diagnoses into the Electronic Medical Record.
- Access and document laboratory results and radiology findings
- Access and display X-rays for the provider to review
- Locate and obtain Past Medical History, previous charts, past results, and recent studies.
- Record physician interpretations of EKGS and X-rays.
Scribes are strictly prohibited from performing the following tasks and duties:
- Touch patients
- Give verbal orders
- Write any orders or prescriptions
- Participated in any activity that may affect the patient’s health or outcome
- Sign or authenticate any chart or medical record
- Handle any body fluids or specimens
- Provide any medication advice or information to the patient.