decisionhealth Newsletters, Part B News - 2013 Issue 9 (September)
Create guidelines, agreements to streamline use of scribes with EHRs
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Article Overview
This article covers practical guidance for practices that use scribes with electronic health records, focusing on documentation workflow, staff roles, record review, authentication, and audit considerations. It is aimed at physicians, practice managers, coders, and compliance staff who need to reduce documentation errors and support accurate billing and legal compliance. The discussion draws on expert commentary and references guidance from AHIMA and Medicare-related sources.
Why This Topic Matters
Scribe workflows can improve documentation efficiency, but they also create risks related to record accuracy, authentication, and billing compliance. Understanding the general documentation and oversight issues helps practices manage EHR-based scribing more safely.
Article Sections
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Scribes, EHR workflow, and practice context
Introduces the use of scribes in physician practices and the move from paper records to electronic workflows. Provides context from practice experience and expert commentary.
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5 tips for using scribes with EHRs documentation
Outlines broad compliance and workflow considerations for practices using scribes with electronic records. The section organizes guidance around policies, access, identification, review, and authentication.
What You Will Learn
- How scribe workflows fit into EHR-based documentation processes
- What types of policy and accountability considerations practices should review
- Why role separation, record review, and authentication matter in scribed documentation
- How audit trail and identity tracking relate to electronic documentation
- What kinds of operational issues can affect billing and legal compliance
Who Should Read This
- Physicians
- Practice managers
- Medical coders
- Billing staff
- Compliance staff
- Health information management professionals
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