What is a scribe in healthcare?

A scribe in healthcare is someone who is hired by a care provider or organization to log medical information gathered from a patient encounter and record that information into the electronic health record system. Medical scribes act as personal assistants to clinicians, completing the bulk of their clerical work and medical documentation so that they can focus more acutely on patient care.

Medical scribes were first seen in healthcare in the mid to late 20th century, but didn’t gain major popularity until around 2010, when the federal government passed HITECH, a sweeping health information and technology act that incentivized care providers to adopt electronic health record systems, thus greatly increasing the documentation load.

A totally redesigned provider reimbursement system led to a massive influx of new data recordation policies, and drastically altered how providers were able to deliver care. For many healthcare providers, it was nearly impossible to keep up with the note taking, charting, EHR documentation, and ICD coding. Enter medical scribes in healthcare.

What are the roles of scribes in healthcare?

Traditionally, scribes are aspiring medical students or young professionals looking to gain industry exposure, and are required to complete some level of basic training before being brought on by a scribe organization or provider team. This knowledge base and training ensures that scribes are able to complete the medically related tasks that are critical to their role. The major responsibilities of a scribe in healthcare are as follows:

Note-Taking

A medical scribe’s most traditional role, per their title, is to log (or scribe) patient visits as they occur in real time. Scribe’s sit in on a patient encounter and track and record the medically relevant information that is discussed during the visit either by hand, or directly into the patient’s electronic health record.

HPI and Family History

In many instances, scribe’s are tasked with filling out a patient’s history of present illness (HPI) and their family history so as to produce more complete medical documentation. Since the passing of HITECH, recordation of HPI, family history, and ROS have become an essential element of patient data and provider reimbursement.

Scheduling

While the main role of a scribe is to relieve in-visit and post-visit documentation, some scribes are enlisted to handle extra administrative tasks like scheduling, follow ups, consultations, and results releases. These responsibilities are what can often make scribes feel indispensable to providers, acting as true personal administrative assistants to healthcare professionals who are bogged down by far too much clerical work.

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The Evolution of Scribes

We’ve discussed scribes in healthcare as they relate to their most traditional iteration, but in the years since HITECH passed, scribes have continued to evolve and take new forms. 

Virtual Scribes

Virtual scribes have the same basic responsibilities as their traditional in-person counterparts, but perform the roles of their job remotely. Oftentimes, virtual scribes listen in on a patient encounter through a secure video or audio connection. This alternative has gained major popularity over the past few years, especially during the COVID-19 pandemic when remote work became a necessity. 

For some healthcare providers, virtual scribes are preferred because their physical presence in an exam room doesn’t intrude or interfere with a visit, and their virtual nature poses a lower risk of “functional creep.” Additionally, virtual scribes are often less costly than their in-person counterparts.

Artificially Intelligent Scribes

The emergence of artificially intelligent scribes in healthcare is a relatively new phenomenon. AI scribes refer to technology that is capable of listening to a patient encounter and extracting the medically relevant information and inputting it into the EHR, just as a scribe would, by using artificial intelligence, machine learning, and natural language processing.

AI scribes in healthcare are the future of medical documentation, as they are cheaper to use, easier to implement, and totally secure. True AI scribes bring the joy of care back to medicine.

‍Learn more about our AI-powered scribe.