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:

  • Doctor-EducationDocumentation 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.