Joint Commission Updates HR FAQ on Use of Unlicensed Persons Acting as Scribes in Hospitals and CAHs

The Joint Commission has updated its FAQ regarding the use of unlicensed persons acting as scribes under the Human Resources (HR) chapter for Hospitals and Critical Access Hospitals (CAHs). The updated FAQ is also available on The Joint Commission website at this link.

Q. What is a scribe and how are they used?

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.

Scribes also assist the practitioners listed above in navigating the EMR and in locating information such as test results and lab results. They can support work flow and documentation for medical record coding.

Scribes are used most frequently, but not exclusively, in emergency departments where they accompany the physician or practitioner and record information into the medical record, with the goal of allowing the physician or practitioner to spend more time with the patient and have accurate documentation. Scribes are sometimes used in other areas of the hospital or ambulatory facility. They can be employed by the healthcare organization, the physician or practitioner or be a contracted service.

Q. Do the Joint Commission standards allow organizations to utilize scribes?

A. The Joint Commission does not endorse nor prohibit the use of scribes. However, if your organization chooses to allow the use of scribes the surveyors will expect to see:

Compliance with all of the Human Resources, Information Management, Leadership (contracted services standard) and Rights and Responsibilities of the Individual standards including but not limited to:

  • A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05)
  • Orientation and training specific to the organization and role (HR.01.04.01, HR.01.05.03)
  • Competency assessment and performance evaluations (HR.01.06.01, HR.01.07.01)
  • If the scribe is employed by the physician all non-employee HR standards also apply (HR.01.02.05 EP 7, HR.01.07.01 EP 5)
  • If the scribe is provided through a contract then the contract standard also applies (LD.04.03.09)
  • Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as do other hospital personnel (IM.02.01.01,IM.02.01.03, IM.02.02.01, RI.01.01.01)

Compliance with the Record of Care and Provision of Care standards also apply and include but are not limited to:

  • Signing (including name and title), dating of all entries into the medical record—electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff. (Example: “Scribed for Dr. X by name of the scribe and title” with the date and time of the entry.)
  • The physician or practitioner must then authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician or practitioner. (RC.01.01.01 and RC.01.02.01)
  • Although allowed in other situations, a physician or practitioner signature stamp is not permitted for use in the authentication of “scribed” entries– the physician or practitioner must actually sign or authenticate through the clinical information system. (RC.01.02.01).
  • The authentication must take place before the physician or practitioner and scribe leave the patient care area since other practitioners may be using the documentation to inform their decisions regarding care, treatment and services. (RC.01.02.01 and RC.01.03.01)
  • Authentication cannot be delegated to another physician or practitioner.
  • The organization implements a performance improvement process to ensure that the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being entered into the medical record by scribes. (RC.01.04.01)

Q. Can scribes enter orders for physicians and practitioners?

A.  The Joint Commission does not support scribes being utilized to enter orders for physicians or practitioners due to the additional risk added to the process.

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