who enters the information into the computerized medical record


A scribe is a worker who enters information into the computer as the physician examines the patient. The appeal is that the doctor can focus on the patient instead of the computer. Although this sounds reasonable, I wonder what the doctor does if he needs patient information only available in the computerized record. Is the doctor now unable to get the patient information without assistance?

It is difficult to ascertain how popular this concept is but it is clearly growing. Loma Linda University Medical Center and Virginia Medical Center in Charlottesville, Virginia are using scribes in the emergency room. I have read estimates that about 200 emergency departments in community hospitals and academic medical centers are using scribes to enter information into the medical record.

The doctors remain responsible for the accuracy of the medical record. Purportedly, they review the record and make appropriate additions and corrections and sign off.

Perhaps this is no different than dictating a History and Physical in some ways. Certainly the doctor does not have to type it. However, if the information entered is time sensitive, such as an order, then what?

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