How is Medical Scribing Different from Medical Transcription?
by Pat Ireland, CMT, AHDI-F
According to Merriam-Webster, scribes can be defined in the following ways:
- As a member of a learned class in ancient Israel through New Testament times, studying the Scriptures and serving as copyists, editors, teachers, and jurists
- As an official or public secretary or clerk
- As a copier of manuscripts
- As a writer
In recording medical documents, the scribe is all of these—well, maybe not studying Scriptures in today’s world, but certainly as official copiers and writers.
A scribe’s background is similar to that of a healthcare documentation specialist (HDS) or medical transcriptionist (MT). Certification is not required to work as a scribe; however, scribes must be familiar with medical terminology, anatomy, pharmaceuticals, as well as medical abbreviations and English grammar and punctuation. Some companies may offer a training program for newly hired scribes, teaching the company’s specific rules and regulations. Certification for HDSs/MTs is not required, but it is becoming more and more important nationally for obtaining a job.
Check out the following links for certification processes and professional associations.
Both medical students and nursing students often perform medical scribing as they begin their studies; however, once they get farther into their schooling and/or career field, they tend to move on. This leads to quite a bit of turnover in the field of scribing, which is not necessarily true for healthcare documentation specialists and medical transcriptionists (HDSs/MTs).
How does heavy turnover affect the scribing field? Well, when a scribe leaves, it means the company has to replace that employee for the provider to which they have been assigned. When a scribe leaves too soon after placement, or if there is frequent turnover with a particular provider, that can lead to client dissatisfaction. The medical transcription service organizations (MTSOs), hospitals, and clinics, who provide this service, strive to have scribes in place with their providers over the long term. Therefore, each new scribe is asked for at least a 1-year commitment upon being hired. HDSs/MTs, however, consider their job as a career unto itself with all the medical specialties involved as rich learning fields. Turnover is not seen as much in this career field.
A scribe’s Performance Coach (PC) actually audits the scribes in real time. The PCs also audit patient charts after they have been prepared. Scribing for more than one physician usually means having more than one Performance Coach. Part of the performance coach’s responsibility is to talk with the scribe’s provider, determine if they have any suggestions or complaints, and get these resolved with the scribe. The ultimate goal is for the provider to be happy with the finished chart. The performance coaches meet with the scribes on a monthly basis, during which time the work for each provider is reviewed for errors, etc., and any problems with the documentation are resolved.
HDSs/MTs have a slightly different set-up. Quality Control (QA) is done on a certain percentage of completed reports with feedback sent to each HDS/MT on errors, blanks, etc., as a learning tool. Too many errors can lead to the employee being put on suspension and/or being counseled by the supervisor. Suspensions may be for 3 months, during which time the HDS/MT is closely followed and after which there may be a reevaluation.
HIPPA privacy is maintained in a scribe environment—patients are notified and required to give consent. For example, the examining physician informs the patient before the visit starts that a scribe will be listening (or will be present in the examining room) and asks patient permission for this. Scribes undergo HIPAA training and have in-services annually that must be completed and documented. This is similar to the HDS/MT experience in which they also undergo yearly HIPAA training with documentation.
Basically, the scribe and the HDS/MT have similar job requirements, as listed below. These illustrate that there is little difference between the professional medical scribe and the professional healthcare documentation specialist/medical transcriptionist.
Similar Job Requirements
- Typing speed of 90+ wpm with high degree of accuracy.
- Knowledge of anatomy, pharmaceuticals, medical terminology
- Knowledge of English grammar and punctuation
- Ability to learn different account specifics
- Ability to research terms and abbreviations
- Ability to concentrate for long periods of time
- Ability to multitask as a scribe or a medical transcriptionist.
- Self-disciplined to work from home or remotely, as necessary.
As for doing research, the AHDI’s new Book of Style & Standards for Clinical Documentation, 4th edition, is beneficial to HDSs, MTs, scribes, performance coaches, QA personnel, and providers. In Medical Scribing, rules of English grammar, punctuation, sentence structure, and abbreviations is not necessarily standard—especially if a physician documents some of the patient record. As a scribe, the spelling, capitalization, and English grammar is cleaned up as much as possible; however, having one style guide for the entire career field would give needed consistency to patient documentation. This resource would aid the performance coaches and quality assurance personnel in their training as well as in reviewing and correcting reports.
In summary, the medical scribe and the HDS/MT have fairly comparable job descriptions and requirements with a couple of obvious differences. Therefore, medical transcriptionists graduating from the Blackstone program should feel free to apply for a job as either a medical scribe or a healthcare documentation specialist/medical transcriptionist.
Recommended Resources for Healthcare Documentation Specialists, Medical Transcriptionists, and Medical Scribes:
Lucci, Susan, HIPAA Compliance Guide & Quick Reference, 2nd edition, (2017), Association for Healthcare Documentation Integrity (AHDI), Modesto, CA
Medical Abbreviations: 55,000 Conveniences at the Expense of Communication and Safety, authored by Neil M. Dais, 16th edition, (2020), available in both print and digital versions, ISBN 978-0-931431-00-5, (722 pages).
The Book of Style & Standards for Clinical Documentation (BOSS4CD), 4th edition, (2020), Association for Healthcare Documentation Integrity (AHDI)—available in print and digital versions, ISBN 9078-0-935229-64-6, (538 pages).