Electronic health records (电子医疗纪录) have had a significant impact on documentation processes and workflow patterns in healthcare, 但结果并不总是积极的. 与电子病历相关的常见抱怨包括信息过载, 行政负担, 可用性问题, 以及脱节的医疗服务提供者与患者的接触. All of these issues contribute to ongoing concerns about patient safety and clinician burnout, particularly as staff shortages and other stressors plague the healthcare industry.1

帮助解决文件和文书方面的负担, healthcare providers and organizations are increasingly using scribes to help document clinical care. Scribes can be unlicensed, certified, or licensed personnel who provide documentation assistance to
医生或其他有执照的医疗保健提供者.2 Scribes also might assist with EHR navigation, data location and retrieval, coding,
以及其他活动.

研究表明，抄写员可能会提高服务提供者的满意度, 提高效率和生产力, 并帮助提供者进行更多的互动
直接与患者沟通，培养更大的信任和患者参与.3

然而, using scribes in healthcare settings requires careful planning and consideration of potential risks. The strategies below can help healthcare providers and organizations develop and implement policies for using scribes to support sound and thorough documentation processes. 

1. 公司lude information specific to scribes in organizational documentation policies. 确保政策符合州和联邦法律, 认证机构和第三方付款人的要求, 专业指导.
2. Develop written job descriptions for scribes that detail required qualifications, 经验, 和培训. Job descriptions and employment contracts also should clearly delineate scribes’ responsibilities, 所需的能力, 以及对生产力的期望.
3. Make sure scribes are proficient with the organization’s EHR system and have individual security rights to access the system. Healthcare providers should advise scribes about how to respond to EHR alerts and notifications that occur during patient encounters.
4. Routinely monitor scribes to ensure they are adhering to the roles and responsibilities defined in their job descriptions and are not practicing beyond the scope of their certification or licensure.* 
5. 在临床接触时向患者介绍抄写员, and explain their role in documenting care and facilitating better provider–patient interactions and communication. Understand and comply with patients’ right to refuse the presence of scribes in the exam room.
6. 检查所有记录员生成的文件，确保其准确性和完整性. Correct any information that is inaccurate or does not thoroughly represent the care provided.
7. 公司lude a statement in the documentation that (a) verifies that the treating clinician provided the services that the scribe documented, (b) explains that a scribe (include the scribe’s name) documented the provision of care, and (c) confirms that the clinician reviewed the documentation for accuracy and completeness.
8. Provide a signature and date/time to confirm review and approval of all scribe generated documentation. Ensure scribes also sign off on all documentation if required by organizational policy. (Note: Some accrediting agencies and third party payers require scribes to sign documentation.)
9. Ensure that review and appropriate signoff of scribe-generated documentation occurs within the timeframe specified in the organization’s documentation policies.
10. Provide orientation and ongoing training for scribes; training should cover federal and state privacy regulations, 组织文档政策/标准, 病人的权利, 等.
11. 定期评估抄写员的能力并审查他们的表现. Audit scribe-generated documentation for compliance with organizational documentation and privacy/security policies.
12. Offer scribes constructive feedback and measurable goals for performance improvement. Consider including key indicators related to scribe functions in organizational quality improvement plans.
13. 监测联邦和州法律的变化, 认可及付款人规定, 专业指导 related to the appropriate use of scribes for documenting clinical care.
14. Ensure healthcare providers know how to independently navigate and operate the EHR system in case a scribe is not available.

资源

• 美国急诊医师学会:抄写常见问题
• American Health Information Management Association: Using Medical Scribes in a Physician Practice
• 家庭执业管理:书记员能为你做什么?
• Medscape:如何使用“抄写员? 抄写规则，解释
• 联合委员会:书记员提供的文件协助

尾注

齐曼，M.埃里克森，C., & Krips, M. (2021). 初级保健机构中医疗抄写员的使用:文献综合.
医疗保健，59(增刊5)，S449-S456. http://doi.org/10.1097 /高.00...
2同前.
3  Ibid; Gidwani, R.阮，C.科福，A.等。. (2017年,九月/十月). 抄写员对医生满意度的影响
患者满意度和作图效率:一项随机对照试验. 家庭医学年鉴，15(5)，427-433.
doi: 10.1370 / afm.2122; Mishra, P.江，J. C., & 格兰特,R. W. (2018). 初级保健医疗抄写员协会
医生工作流程和患者体验. 中华医学会内科杂志，178(11)，1467-1472.
doi: 10.1001 / jamainternmed.2018.3956; Shultz, C. G., & Holmstrom H. L. (2015). 医疗抄写员在健康方面的使用
护理环境:系统回顾和未来方向. 美国家庭医学委员会杂志，28(3);
371-381.

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. 因为适用于你的情况的事实可能会有所不同, 或者您所在司法管辖区适用的法律可能不同, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, 州或联邦法律, 合同的解释, 或者其他法律问题.

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