This project thus seeks to fill these gaps through eliciting and describing the perspectives of physicians, clinical scribes, and patients regarding clinical scribes in the primary care setting. 17 They offer little insight into the dynamic interactions and relationships among physician, clinical scribes, and patients. Existing studies of clinical scribes are few with data restricted to efficiency 16 and patient–physician face time. In consideration of the heterogeneity of training and work experience among clinical scribes, 14 clinics applying team documentation conduct onsite training that include EHR navigation, clinical shadowing, and continued project management follow-up.
#Medical scribe note example update
To perform the additional documentation duty, they remain in the examination room during the physician–patient encounter and utilize EHR templates to update history, physical exam findings, prescriptions, and necessary orders in real time. 14– 16Īs clinical scribes, MAs and nurses are hired individually and retain usual duties of gathering information during patient intake, assisting with physician in-baskets, fielding patient phone calls, and performing clinical tasks such as in-office testing and immunizations. 12, 13 In particular, the role of medical assistants (MAs) and nurses have been expanded to include clinical scribing, also known as team documentation. 3, 6, 7 Combined with a national shortage of primary care physicians 8– 10 and increasing physician burnout, 11 these concerns have sparked efforts to redistribute responsibilities in an expanded primary care team.
Though implementation of electronic health records (EHRs) has been shown to have positive effects in quality and cost of care, 1, 2 concerns have arisen regarding the impact of EHR use on patient–physician relationships, 3– 5 particularly the computer’s negative influence on overall patient centeredness.
Future directions for research regarding clinical scribes include study of care continuity, scribe medical knowledge, and scribe burnout. CONCLUSIONSīoth interpersonal fit between physician and scribe, and system level support including adequate training, transition time, and staffing support are necessary for successful use of clinical scribes. Our theoretical model for successful physician-scribe teams emphasizes the importance of interpersonal aspects such as communication, mutual respect, and adaptability, as well as system level support such as training and staffing. The resulting shift in workflow, however, led to stress. Clinical scribes also performed more active roles during a patient visit, leading to formation of positive scribe–patient relationships. Most patients were comfortable with the scribe’s presence and perceived increased attention from their physicians. KEY RESULTSĭespite physician concerns regarding terminology within notes, physicians, clinical scribes, and patients perceived more detailed notes because of real-time documentation by scribes. Participants included 18 physicians and 17 clinical scribes from six healthcare systems, and 36 patients from one healthcare system. We used qualitative content analysis, using Interpretive Description of semi-structured audio-recorded in-person and telephone interviews.
The purpose of this project is to describe perspectives of physicians, clinical scribes, and patients regarding clinical scribes in primary care. Despite the use of these clinical scribes, little is known regarding interactions among and perspectives of the involved parties: physicians, clinical scribes, and patients. Extending medical assistants and nursing roles to include in-visit documentation is a recent innovation in the age of electronic health records.
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