Here's a recent question we received from a potential student: I have read a little bit about scribing but do not fully understand how it is implemented on the job or how it fits in with medical transcription, please explain. Is one person responsible for both?
Answer from Ms. Balderrama-Martinez, MT instructor: I am sure there is a lot of misinformation out there, so I will try to clarify. When performing medical transcription, the transcriptionist is typically sitting at a computer either in a clinic or hospital setting and there is no patient interaction. You are transcribing medical reports and they vary based on specialty. Radiology reports like x-rays, CT scans, MRIs, ultrasound reports - these are typically transcribed on-site as the reports are needed immediately, or at least within 24 hours. The same for a hospital setting, a history and physical report or an operative report is needed ASAP. When you are working as a "medical scribe" you are performing the same duties as a medical transcriptionist; however, you are in the Emergency Room, or in the patient room with the physician or medical provider (nurse practitioner or physician assistant).
I have worked in orthopedic surgery clinics training scribes and working with the orthopedic surgeons to help fine tune a medical scribe program as the surgeons strived to provide one on one care to their patients, and still maintain their patient medical records utilizing EMR (electronic medical record) software. When the physician or medical provider is documenting the patient information themselves they are interacting with the laptop, not the patient. I can assure you, the patients were not happy with that arrangement. By utilizing medical scribes, the physician is able to dictate to the scribe as he is performing the physical exam on the patient, he is able to dictate his review of the x-ray findings as he is viewing them, etc.
When done well, utilizing a medical scribe is the definition of economy in motion. The physician/provider is able to maintain excellent electronic medical records, the patient receives better than adequate medical care as their record is created in their presence, and though there are times when the progress note has to be amended to add additional information following the office visit, it is a great asset to have a trained medical scribe on staff.
I have had many physicians approach me and ask me how to institute this type of program in their office so they don't have to spend nights and weekends getting caught up on their dictation. Emergency Rooms across the country have been using scribes for some time now. I believe as the requirements for
Meaningful Use and electronic medical records become stricter, there will be more and more medical scribes along with medical transcriptionists working in clinics and hospitals.
To answer your question, yes one person can do both. There are letters which are typically sent from one physician to another with patient information shared, and so there are times when a scribe is transcribing from dictation as well. This is completely dependent upon when and where you are working.
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