Health Information Compliance Alert

Physician assistants can direct scribes.

Thanks to a new update by the Joint Commission, physician assistants are now permitted to direct scribes in a healthcare setting to record practitioners' notes. This policy revision has helped clear the air over just which clinicians can receive help from scribes -- though the role of the scribe remains unchanged.

Background: Previously, TJC specified that a PA was not considered an independent licensed practitioner, a requirement for being able to use scribes. This was problematic in any healthcare setting, where scribe use is growing to speed efficiency, especially with complex electronic health records, says Mike Granovsky, MD, FACEP, CPC, President of LogixHealth in Bedford, MA.

Compare the two versions of TJC language that follow to see the important change:

Old language: [The Joint Commission Use of Unlicensed Persons Acting as Scribes, May 18, 2011]

A. A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or licensed independent practitioner (APRNs are considered licensed independent practitioners in some states, Physician Assistants are not considered licensed independent practitioners). It is the Joint Commission's stand that the scribe does not and may not act independently but documents the physician's or licensed independent practitioner's dictation and/or activities.

However, the new language in the revised TJC statement removes that specific restriction.

New language: [The Joint Commission Use of Unlicensed Persons Acting as Scribes, Revised | July 12, 2012]

A. A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant). It is the Joint Commission's stand that the scribe does not and may not act independently but can document the previously determined physician's or practitioner's dictation and/or activities.

Resource: The new Joint Commission document can be viewed at the following link: www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQChapterId=19&StandardsFAQId=426#.UAbQCBXYg0M.email

Scribe Role Is Similar, Regardless Of Provider

This is an important change in practices and even hospital settings, where scribes also assist the non-physician practitioners listed above. Scribes essentially support work flow and documentation for medical record coding. They are used most frequently, but not exclusively, in emergency departments where they accompany the physician or practitioner and record information into the medical record. The goal is to allow the physician or practitioner to spend more time with the patient and have accurate documentation such as helping locate in the EHR a patients' test results and lab results.

Scribes are sometimes used in areas of the hospital or ambulatory facility other than the ED. They can be employed by the healthcare organization, the physician or practitioner or be a contracted service.

Caveat: Remember that the scribe must function as a human tape recorder and not independently document any findings of their own, says Granovsky.