Scribes are playing an increasingly important role in the emergency room as more departments look for ways to ease physician documentation burdens and improve patient throughput.
Scribes follow physicians during the exam and treatment process and enter clinical observations and activities into the electronic health record (EHR). This support allows physicians to focus more fully on clinical decision-making and can also improve documentation accuracy.
“We’ve seen the utilization of scribes increase dramatically among our clients over the past two or three years,” said Deborah Grieve, McKesson Business Performance Services (McKesson) emergency department coding supervisor. “I’d estimate that probably half of our clients are using scribes.”
Studies estimate that an average emergency physician spends between 30-40% of their shift time documenting cases.1 Because documenting into an EHR can be slower than traditional paper methods, a capable scribe represents a powerful resource for expediting documentation and work-flow management duties.
In addition to tracking physical exam results as dictated by the physician, scribes can record vital signs, laboratory and radiology results and pull medical records. They also can document communications with consultants and reduce interruptions by receiving information from support staff.2
Identifying critical care time
Individuals providing scribe services can vary from medical school students seeking hands-on emergency room experience to full-time professionals employed by outsource staffing companies. In all cases, Grieve said, it is important that scribes receive appropriate and ongoing documentation training.
Along with a thorough understanding of the clinical and anatomical details required to document for ICD-10 coding, scribes should be trained to recognize situations or events that can trigger critical care time. Critical care represents the highest level evaluation and management (E&M) service and is defined as a physician’s direct delivery of medical care for a critically ill or critically injured patient.
Typically, critical care services involve high-complexity decision-making to assess, manipulate and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.3
Although the physician may be generally aware that a critical-care event has been triggered, Grieve said they sometimes miss documenting the information due to the immediate demands of the case. As a result, the scribe should be in a position to recognize a critical care situation and verbally prompt the physician.
“We hear from doctors all the time that they didn’t think about critical care during the time they were treating a particular patient, and it’s easy to understand why,” Grieve “That’s why scribes should be aware of what constitutes critical care, flag the event, and make sure physicians have signed off on it correctly so they can be appropriately reimbursed for the services provided.”
Deb Mowry, director of operations for McKesson’s Emergency Center of Excellence in Grand Rapids, Mich., said many scribe staffing companies provide an onsite supervisor that can help coordinate scribe training, including critical care awareness. The supervisors also serve as a go-to resource for documentation questions that arise during an episode of care.
Securing physician sign-off
According to Mowry, one of the most common problems involving scribe utilization is the absence of physician approval for the completed documentation. This typically happens when the physician fails to complete and sign off on a chart review, or when an EHR forwards the chart to coding before the physician has had a chance to look at it.
Either way, the mistake inevitably results in a delay in submitting the claim, since the chart must be returned to the physician. Practices should therefore reinforce to physicians the importance of a prompt and thorough review. And if the failure is due to premature transmittal of the chart, information technology staff should be alerted and asked to modify the system so that the chart is held until the review process has been completed.
“Scribes can be a very effective addition to emergency departments, providing they are properly trained and led,” Mowry said. “This is especially true in today’s era of increased documentation demands associated with ICD-10.”