What Are Medical Scribes?

A medical scribe is a clerical assistant to a physician or other medical provider who types patient medical information into their EHR for them. The job of a “medical scribe” (also called medical documentation specialist or clinical information manager) developed out of a focus on EMR/EHR implementation in medical practices, hospitals, and surgery centers and is vital to effective patient care. 

How Medical Scribes Work

Medical scribes typically work in one of two ways: they either shadow doctors and record notes on a patient’s chart from within the exam room, or they are remoted into exam rooms through videoconferencing or audio/video connections to transcribe notes into a patient’s chart from a different location. 

The trend of using medical scribes developed from the government’s push for EHR adoption. Physicians, unhappy with the new burden of typing their own notes into an EMR and the errors in voice recognition systems, started using medical scribes as an alternative to charting themselves. 

While their work primarily revolves around clerical duties and information administration, medical scribes are often required to be familiar with or specialize in different healthcare practices. This ensures that the scribe is familiar with medical terminology and that all captured information is accurate and complete. Medical professionals may hire their scribes based on such qualifications.

Furthermore, education varies significantly as no formal training or certification program is universally accepted to become a medical scribe. Many scribes are either former transcriptionists who transitioned into this new role or pre-med students who take the position for on-the-job training. 

Additionally, some providers outsource the task by sending patient notes to a 3rd party, such as Ditto Transcripts, to take on the job. The result is fewer clerical tasks, doctors seeing more patients, increased patient satisfaction, and improved document quality.

Responsibilities of a Medical Scribe

The role of a medical scribe can often be wide and varied and is usually dependent on the requirements of the healthcare professional or practice they are employed with. The most common functions are listed below: 

  • Documentation and Data Entry: The primary responsibility of medical scribes is documentation and clerical tasks. These functions cover all patient encounters, including symptoms, physical examination results, medical histories, physician diagnoses, treatment plans, and other relevant details. Data entry procedures vary, but the implementation of EHR guidelines has helped standardize such procedures. 
  • Real-time Charting: Scribes may be responsible for charting patient information during the patient visit, allowing doctors to focus more on listening to the patient instead of taking notes. This improves the patient’s experience and minimizes healthcare-related lawsuit risks like poor communication, misdiagnoses, informed consent issues, and overall patient dissatisfaction.
  • Transcription: Scribes may transcribe physicians’ verbal dictations (verbatim or shorthand) and notes from healthcare providers into EHR systems to ensure that all patient information is accurately recorded.
  • Order Entry: Medical scribes may need to send orders for laboratory tests, medication, imaging requests, and others, as required by the healthcare provider. These orders are usually done through the EHR, and follow-ups can be done through phone calls or instant messaging.
  • Patient Communication: Medical scribes may need to facilitate communication between healthcare providers and patients by explaining procedures, obtaining consent, and answering non-medical questions. This requires baseline medical knowledge and effective communication skills.
  • Other Administrative Tasks: Medical scribes may perform other clerical and administrative tasks as the healthcare provider requires.

The Cost of Hiring In-house Medical Scribes

A medical scribe’s average salary is between $55,000 and $75,000 a year, depending on their years of experience and education level. This does not include any vacation, bonuses, health insurance, or other costs associated with hiring an employee, which typically adds about 30% more to an employee’s overall cost to their employer.

Virtual Medical Scribes 

Virtual medical scribes can offer physicians and other healthcare professionals the same administrative and clerical assistance without being physically present. Such procedures are facilitated via an internet connection, which is ubiquitous in today’s interconnected environment. 

Hiring virtual medical scribes can help hospitals and clinics save on employee training, office space, and equipment expenses. This is a more cost-effective solution than hiring permanently in-house. 

Additionally, patients can feel more at ease during visits. Having a third person during checkups may be a source of anxiety for patients, keeping them from giving all relevant information about their conditions. With virtual medical scribes, checkups and workups can be held in relative privacy, with patients only ever interacting with their healthcare provider. 

The flexibility remote work offers is also a great advantage to medical facilities with varying personnel requirements. For example, shortages of in-house medical scribes can be supplemented with virtual scribes. The remote scribes can be onboarded with little fuss and kept around depending on workforce requirements. 

Is Hiring Virtual Scribes Feasible?

Before Electronic Health Records (EHR) implementation, most doctors dictated their notes and had someone transcribe them, either from within their office or by using a medical transcription service. Today, many physicians and practices assume they can’t use an outside service as their EHR transcription company that can work directly inside their systems, which couldn’t be further from the truth.

The main concern comes from access to the Electronic Health Records system the healthcare facility uses. Since virtual medical scribes aren’t physically present in the hospital, they can sometimes not be granted access to the system for proximity and security reasons. 

However, many transcription companies, including Ditto Transcripts, have an interface that “pushes” the transcribed note into the EHR or EMR system, putting the data into the correct fields and fulfilling Meaningful Use requirements. This satisfies the Medicare/Medicaid reimbursement requirements. Hiring virtual medical scribes can also save physicians and other healthcare providers money in the long run. 

Most transcription companies charge by the line, so you only pay for the work the company returns to you, not an hourly or salary rate as with a medical scribe or an in-house medical transcriptionist. This setup allows for more budget flexibility, which is a premium nowadays, considering the increasing costs of hiring and training an employee to serve a specific function. 

You can also expand the workload and hire a remote medical scribe to do your documentation. They have turn-around times between 2 and 24 hours, so physicians won’t miss deadlines, and billing can be done the same day.

Security and HIPAA Compliance

Security and privacy are immensely important in the medical field. The Health Insurance Portability and Accountability Act, or HIPAA, is a federal law and national standard that protects patients’ private information. The law covers the storage and transmission of patient information. It enforces rules that protect private data while facilitating the free transfer of information between healthcare companies and auxiliary service providers. 

Healthcare providers, companies, and service providers like scribes and transcription companies connected to healthcare (known as “covered entities” in the law) must comply with HIPAA guidelines. Physicians, clinics, and hospitals looking to hire virtual medical scribes must consider HIPAA compliance before choosing. 

How Ditto Transcripts Can Help With Your Medical Scribe Needs

There are plenty of companies offering virtual medical scribing services. Quality and service levels vary, like in any industry, but the best way to gauge if a provider is the right fit for your practice is to study the features and services they bring to the table. Ditto Transcripts, for instance, humbly offers the following:

Accurate and 100% U.S.-based Human Transcription

Many service providers incorporate automated software into their processes, making faster transcription. The tradeoff, however, is any project completed by the automated process has lower accuracy rates and requires human intervention. Having only human medical scribes — all from and currently residing in the U.S. — allows Ditto to reach accuracy rates of up to 99%. 

Experienced Talent at Your Fingertips

Ditto’s medical scribes are trained in common and specialty medical terminologies, making them effective in any medical field. Here are some of the specialties that Ditto covers:

  • Primary Care
  • Internal Medicine
  • Family Medicine
  • Pediatrics
  • Cardiology
  • Oncology
  • Nephrology
  • Dermatological surgery
  • Ophthalmology
  • Otolaryngology/ENT
  • Podiatry
  • Neurology
  • Pulmonary
  • OB/GYN
  • Physical Medicine & Rehabilitation
  • Mental Health Services
  • General surgery
  • Plastic surgery
  • Spine surgery
  • Orthopedic surgery
  • Breast surgery
  • Urology surgery

Unparalleled Flexibility and Customization

Ditto works with you for anything you need. We can accommodate rush requests; depending on your desired turnaround time, your reports will be ready in two to 24 hours. We also accommodate customized reporting formats and other requests. 

Our extensive experience with healthcare professionals allows us to work with any Electronic Health Record or Electronic Medical Record system. You can call in your reports and use an iPhone, Android, or handheld digital recorder. All the fields will be mapped out, and your information will be inserted into your EHR or EMR as if you did it yourself. 

Security and Confidentiality

Ditto is fully HIPAA-compliant, meaning all your data is protected from unauthorized access and other security threats. Ditto Transcripts is a Denver, Colorado-based, HIPAA-compliant medical transcription company that provides fast, accurate, and reliable transcription services for hospitals, clinics, facilities, and individual practices of all sizes. Call (720) 287-3710 today for a free quote, and ask about our free five-day trial. Visit our website for more information about our medical transcription services.

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