Generally, a physician’s main task is to focus on direct patient care. During visits, a physician has to collect all the pertinent information related to the patient and document it. This non-clinical documentation and clerical work became more strenuous with the evolution of Electronic Health Record (EHR), ultimately slowing down the physician’s ability to perform in actual patient care clinically. Here is where the medical scribes entered to support the physicians’ non-clinical work.
A study done in 2016 has revealed that the physicians spent about 21% of the time on documenting and paperwork. Medical scribes were incorporated to assist the physicians in documenting and maintaining patients’ clinical history, laboratory and radiological results, compliance with meaningful use, and data entry for Electronic Health Record.
Table of Contents
- Physician’s Secret Weapon – Medical Scribes
- Who is a Medical Scribe?
- What does a Medical Scribe do?
- How does a Medical Scribe help a Physician?
- What is the Average Salary for Medical Scribe Professionals?
- Companies That Hire Medical Scribes
- Where to get Medical Scribe Training?
- Medical Scribe Job Description
- Skills Required For A Medical Scribe
- Medical Scribe Certification
- Scribe Legal Considerations
- Implement Scribe Documentation Guidelines
- Frequently Asked Questions
Who is a Medical Scribe?
A medical scribe is a paraprofessional who assists the physicians in various tasks such as documenting, coding, recording radiology and laboratory results, entering data into EHR, etc. They ease the physician’s work by documenting the physician and the patient’s interactions, entering patient information into the database, and writing down the notes when the physician dictates. They also help in scheduling consults and assist in obtaining medical records from other facilities.
Overall, a medical scribe amends the efficiency of the encounters between physician and patient, which helps the doctor focus entirely on patient care rather than clerical work.
What does a Medical Scribe do?
A medical scribe records the patient’s details, including their anamnesis (medical history), social history, diagnosis, clinical procedures performed, present complaints, medical orders, clinical test prescriptions, etc. A scribe is a personal assistant to the physician in various aspects. They may also work one or more shifts with one or multiple physicians. Medical scribes are also required to assist the physicians in the emergency department and document the patient’s illness history, review of systems or ROS, physical examination, prescriptions, and patient’s discharge plans alongside keeping track of laboratory and radiologic records, typewrite progress notes, etc.
They may also be required to do other tasks depending on the physicians they assist.
How does a Medical Scribe help a Physician?
A medical scribe primarily helps a physician with the day’s clinical work to make lists or chart a patient’s encounter using an electronic health record (EHR). Their responsibilities vary according to the physician’s department rules. The scribe book appointments, generate referrals, and manage all sorts of documents within the EHR system. They investigate patients and their information related to the diagnosis or reports on behalf of the physician.
It wouldn’t be incorrect to call scribes as a data manager or clerical assistants whose contributions help the physicians, nurses, and other medical assistants to focus on their clinical patient care. By managing a physician’s task, they increase the patient’s meeting duration and frequency. The better workflow in the department generates productivity.
EHR is application software, which systematically stores information of the patients digitally with secure authorization to other users; it contains all the patients’ clinical data and is built with a broader vision to assist the medical departments in various aspects.
One of the key features of the EHR is the accessibility of the records between the providers of more than one organization whenever necessary so that they can make an informed decision. However, the complexity arises when the physicians must spare more time feeding the information and creating records, resulting in the provider’s burnout and job dissatisfaction. Therefore, the scribe comes in for support for the increasing disarrangement. Patients have also been seen to be willingly fine or unbothered with their presence during the examination.
With a scribe’s help, a physician is relieved from doing any administrative work such as data entry, record keeping, charting, etc. A scribe’s work is very thorough and accurate, hence used for insurance billing purposes too.
What is the Average Salary for Medical Scribe Professionals?
Salary and benefits depend largely on the geographic location, and various other factors determine the medical scribe’s income. A medical scribe can anticipate earning somewhere around $9.00 to $15.00 an hour. The average income of a scribe in the US is $14/hour. Apart from the geographical location, other factors that also determine a medical scribe’s income include:
- Employment Setting
- Relevant Work Experience
- Educational Qualification
There is no specific mention of the salary statistics information, but their data shows their average income record. Their package is anywhere between $18,000 and $37,000 annually, the national average being $20,000. Here, the pay scale differs according to the experience and workload. More often, an experienced ER Scribe posted in the emergency department or other specialties like Cardiology may get a higher pay package than general medicine due to the hectic work environment and work schedule.
The Head of the Scribes gets the best pay package. They are also required to mentor the apprentice or callow scribes.
|CITY||AVERAGE INCOME(Per Annum)||INCOME/HOUR|
|New York States||$30,000|
|New York City||$33,000|
|New Jersey||$31,000||$14 and $15|
|California||$14 and $15$20 (Depending on experience)|
|Oregon||$9 and $15|
|Minnesota||$29,500||$9 and $16|
|Florida||$12 and $14|
There may be variations in the above chart. It is just for informational purposes.
Large medical scribe employment agencies hire candidates, train, and pay them. These agencies provide scribe services to healthcare organizations to serve the hospital and their physicians. Multiple agencies are assorted with various paying structures and benefits that take the initiatives and responsibilities for an end-to-end service. The major scribe companies include ScribeAmerica, PhysAssist Scribes, ScribeKick, Medical Scribes, and more.
|COMPANY||AVERAGE ESTIMATED SALARY|
|Elite Medical Scribes||$8-$9/hour|
|PhysAssist Scribes||$8-$10/hour, variable|
Companies That Hire Medical Scribes
ScribeAmerica is one of the largest medical scribe agencies with training programs, generating employment nationwide for over 13,000 full and part-time scribes. Their scribes get placed in various medical settings ranging from smaller to larger hospitals, private practice, and teaching facilities. Scribes who work full-time for more than 36 hours per week get good perks and benefits. They also generate job opportunities for project leaders and project managers.
ProScribe provides classroom and clinical training for its employees. Exams will be conducted for trainees, and eligible candidates will be escalated for professional experience. ProScribe provides annual increments and various other benefits for their full-time employees.
ELITE MEDICAL SCRIBES
Elite Medical Scribes was established in 2008, headquartered in Bloomington, Minnesota, with many regional offices in other states. They provide online classes and medical scribe trainer guides through clinical experience. They provide flexible part-time schedules and advancements for the scribes.
American Scribes hires specifically pre-med students or fresh graduates of pre-med degree who are aspirants for healthcare. It comes as help at hand for those seeking upward mobility in medicine. They provide extensive clinical experience, and selected candidates must serve at least a two-year term.
PhysAssist Scribes provides classroom and clinical training. Their salary structure is variable according to the state. There is scope for a better pay scale with experience and advancement and can promote higher positions such as trainers and chief scribes.
ScribeKick offers virtual scribes and onsite medical scribes. The company specializes in training its scribes in medical procedures and terminologies. Their scribes mostly work full-time in a variety of clinical settings. Companies especially prefer to hire ScribeKick due to their virtual scribes’ availability, but that doesn’t decrease the on-site employees’ expertise. They offer good pay and benefits to their eligible employees with advancement.
Where to get Medical Scribe Training?
Many organizations and agencies provide on-site and virtual scribes to healthcare organizations. The agencies prepare them through training and certify them as service vendors. The minimum qualification required for a medical scribe job is a high school diploma; however, many apprentices opt to gain experience.
Few agencies may require their scribe to get a work background; seldom has it happened that a degree in science is a joy of joys, especially if gained in biology or pre-med. A scribe may expect an upper hand at this stage as this provides more room for learning and application of the gained knowledge. A Medical Scribe’s job is to work manifold when placed under a physician, to cater to all the various tasks they need to experience, all the responsibilities on all the job-related topics, which include:
- Anatomy and Physiology – Study of the living thing’s structural organization, i.e., human being, so that one may have a fair understanding of the organs’ functions.
- Bloodborne Pathogens – Microorganisms that infuse infections in the blood.
- Discharge Procedures – Hospital discharges a patient when they no longer require the care as an inpatient. At times, the procedure is a lengthy process to handle alone if the patient’s inmates are not available. Scribes are required to help in instructing or going the extra mile to achieve the same.
- Basic Coding and Medical Terminology
- Medical Billing
- General Medical Knowledge
- Radiology, EKG, MRI, and other results
- HIPAA and other Medicolegal and patient privacy
- Medical and legal documentation
- Workflow Management – Even if working under an extreme or rigorous condition, to deliver medical care.
Medical Scribe Job Description
As already discussed, a medical scribe’s job is to assist their assigned physician in his or her work for increasing accuracy and efficiency in recording the patient’s clinical history in all kinds of medical settings. Their soft skill is apt as they record and document the day’s work by actively listening and writing down all the communications between the physician and the patient. Therefore, they are expected to have advanced training on the same criteria since utilizing medical documentation software.
Skills Required For A Medical Scribe
1. Paying Attention to the Details
Medical scribe’s various skills include accurate recording notes dictated by physicians and patient information and investigating their medical history.
2. Computer Literacy
Since the medical records are maintained on a database, a scribe must know how to operate a computer system, record and read the patient’s information. Technology adaptation is a must with good typing skills and data entry capabilities.
A medical scribe should have good verbal and written communication skills since they will be required to interact with physicians, patients, and other medical professionals. They must be able to interact comfortably with others via phone or e-mail.
4. Time Management
It is no surprise that a doctor’s task is one of the most critical interactive jobs. Their time utilization must be done efficiently as they meet and perform an examination on several patients throughout the day. Such things have to be managed by their scribes swiftly, yet in a detailed manner, processing the patient’s information to move over to the next patient in line or move onto the next task on the list. Working in a fast-paced environment must come in handy for the scribe to substantially manage their own time.
5. Bedside Manner
Bedside manner is an attitude with which a doctor approaches their patients. Since a medical scribe’s task is similar to shadowing a physician’s job, bedside manner is similarly important for a medical scribe to possess. They must be empathetic and understand a patient’s situation, assist the patients in need and help with paperwork by giving them clear instructions.
A scribe’s duty here will be to provide all the instructions clearly and supportively whenever they can.
Medical Scribe Certification
American Healthcare Documentation Professionals Group provides certification of a scribe through their Medical Scribe Certificate Exam. While the certification has not been essential, many employers would like to have their scribes certified as it adds value and professionalism.
An examination is conducted to judge the applicant’s knowledge and ability to judge. There will be 100 questions, and one has to acquire a minimum of 80% to receive the certification. The exam fee is $165, and the study material to prepare for the exam is provided by the American Healthcare Documentation Professionals Group itself.
Scribe Legal Considerations
There is not much information in the healthcare atmosphere that addresses the legal issues brought to notice while using scribes. Regulation has not prohibited using a scribe, but the policy guidelines and conditions differ; for instance, a scribe may have many undertakings and responsibilities in one care setting, but it may vary in the other with more restrictions, with less workload.
The state law must be thoroughly reviewed so that it ensures compliance and proper use of scribes. If a state doesn’t allow an uncertified scribe, then it should be foreseen before allowing any scribe to the setting.
Scribes’ responsibilities are more or less controlled by the organization’s regulatory requirements and their establishments of policies. As the scribes in the healthcare world are more prevalent, the necessity for legal direction grows ultimately. Proper monitoring should be done to see if any state or federal regulation is met with compliance standards.
Implement Scribe Documentation Guidelines
It suggests that a guideline is often conducted for the scribes from their service place that needs to be followed. In addition to the normal documentation, a scribe would be carrying a separate duty list with authentication, which by rule suggests many clauses that may have been differently documented in a different setting. They may include:
- Must complete all the entries in the provider’s physical presence.
- Must document the recording of the patient’s health information under the provider’s direction.
- The authentication of all the entries should be completed on time as defined by the regulatory requirements.
- They are individually assigned the rights to EHR.
- The provider must guide their scribe to read the alerts and advise on the proper responses to be initiated as and whenever it appears on the screen.
- Suppose the agency or third party is responsible for the scribe payment, in that case, they must have specific guidelines and the procedure to go about it, which includes a scribe’s documentation and their application of electronic signature. The facility must contact the agency for further requirements.
- Their guidelines of the Joint Commission was released in 2011 for the scribes to be used by various settings to help and regulate the use of scribes:
- Verbal orders must not be given to the scribes nor taken by the scribes.
- Signature must include name, title, and date; necessary for all the medical records documented electronically and manually.
- Mentioning the timing is required for the organizations that use jointly commissioned accreditation for the deemed status.
- The scribe’s signature and role must be distinguishable and identifiable from that of the physicians and other staff. For example: “Scribed for Dr. Drake Ramoray by Phoebe Buffay, on 12/12/2019, at 8:30 pm.”
- Specific orientation and training must be given apropos.
- Assessment and evaluation of their competence must be performed regularly.
- Scribes must meet HIPAA, HITECH, confidentiality, and patient rights standards, like other hospital personnel.
- Non-employee standards are applied to the scribes, in case the physicians employ the scribe.
Frequently Asked Questions
1. How beneficial is a medical scribe’s job?
The job benefits an individual or a pre-med student by polishing their knowledge and skills required for a medical oriented environment. It could also be an extra income if someone takes it as a part-time opportunity to pay off their EMIs, loan, saving for further medical studies, etc., working closely alongside the physicians.
This job is more on the emotional than the rational front. It usually feels strengthening for people to have their input or say involvement in a wise profession and get validated. It fosters ownership and inclusion in a group of healthcare providers.
2. Is it hard to get a medical scribe job?
If you go through a company or agency, then it is relatively easier than getting self-employed as they always have requirements. If selected, you will have to commit for a year to two at the most.
3. How much demand does the medical scribe profession gather?
There is an ongoing increasing demand for the medical scribe in the US as they share the physician’s load of work and perform efficiently even when the pressure bar rises from the patient’s side upon them. They are often helpful in providing quality care efficiently and generously.