The Joint Commission announced the following updated guidance for scribes and/or documentation assistants this week:
Definition: A documentation assistant or scribe may be an unlicensed, certified, (MA, ophthalmic tech) or licensed person (RN, LPN, PA) who provides documentation assistance to a physician or other licensed independent practitioner (such as a nursing practitioner) consistent with the roles and responsibilities defined in the job description, and within the scope of his or her certification or licensure.
Persons in the Role of Scribe and/or Documentation Assistants must have a job description and shall have the following competencies/education as a minimum standard:
- Medical terminology
- Principles of billing, coding, and reimbursement
- Ability to navigate and understand the functionality of the organization’s Electronic medical record (EMR) as needed to function within their assigned duties
- Computerized order entry, clinical decision support and reminders, and proper methods for pending orders for authentication and submission
TJC advises the amount of training required in these areas will vary depending upon the person’s past training and experience.
Organization should develop a policy/procedure regarding processes associated with the use of documentation assistants. Policies should:
- Restrict /prohibit documentation assistants/scribes from using a physician or LIP’s log-in and define the proper log-in procedures and purpose.
- Define the scope of documentation that may be entered by the documentation assistant/ scribe
- Sets forth the requirements for physician review of information and orders entered by the documentation assistant, and the order entry and submission process.
In alignment with the other standards in the Human Resources Chapter that apply to those who provide care, treatment and/or services to your patients; orientation and ongoing training and education to the role must be provided.
Organizations that elect to provide these services through a contractual arrangement are reminded that all clinical contracting requirements apply.
Orders: All types of personnel performing documentation assistance may, at the direction of a physician or another LIP, enter orders into an EMR. The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders. Documentation assistants who are not authorized to submit orders should leave the order as pending for a certified or licensed personnel to activate or submit the orders after verification. These specifications should be outlined within the organization’s policies and procedures and /or job descriptions.
Transcribing orders into the EMR while providing documentation assistance is not considered a verbal order. Verbal orders are different because they are expected to be acted upon immediately by individuals who are practicing within the scope of their licensure, certification, or practice in accordance with law and regulation as well as with organizational policy.
TJC has not indicated how the above guidance will be used as a component of the survey process.