Medical Records are both Medical and Legal records. The accuracy of our medical records is vital to our ability to provide quality care, it is even more vital when we share our medical records with other providers and they use that information as part of their medical decision making process. If errors and inaccuracies find their way into our medical records this can also have an impact when our charts are audited for payment purposes or when our records are used for medical legal issues. Two recent studies looked at the use of scribes and the impact on the accuracy of medical records. A study published by the Journal of Medical Informatics looked at the accuracy of medical records created using a scribe. (http://medinform.jmir.org/2017/3/e30/). The study demonstrated a significant variability among scribes. among scribes.
"Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%."
This study was completed by videotaping five experienced scribes. The general conclusion was “There was significant interscribe variability in note structure and content. Overall, only 26 percent of all data elements were unique to the scribe writing them,”
A second study by Dr Jeffrey Gold at Oregon Health and Science University (http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/Take-No...) comes to the following conclusions:
There is a lack of standardized training of scribes.
There is no conclusive data on the use of scribes and patient safety.
There are no rules on the role of scribes in the medical environment.
Based upon a survey by the Doctors Company:
55 percent of scribes are trained by the doctor.
44 percent of scribes have had no prior experience.
Only 22 percent of scribes have had any form of certification.
Around 24 percent of practices that use scribes hire them as employees.
Nearly 13 percent of practices use scribe staffing agencies.
This variability in the role of the scribe coupled with the variability of the data entered by the scribe creates potential questions for any medical record that was created with the use of a scribe. If you are utilizing a scribe in your practice or you are considering the use of a scribe it is important for you to monitor the work of the scribe and review all information entered into the medical record by the scribe. Once you engage in these tasks, the cost savings and convenience associated with employing scribes in your practice may be lost.
This particular situation has many implications, financial, medical and legal and all implications must be taken into account when deciding on the use of a scribe in the medical environment.