电子健康记录(ehr)对医疗保健行业的文档处理和工作流程模式产生了重大影响, but the results have not always been positive. Common complaints associated with EHRs include information overload, administrative burden, usability issues, and disjointed provider–patient encounters. 所有这些问题都引起了对患者安全和临床医生职业倦怠的持续关注, 尤其是在医护人员短缺和其他压力因素困扰着医疗行业的情况下.1

To help address documentation and clerical burdens, 医疗保健提供者和组织越来越多地使用抄写员来帮助记录临床护理. 抄写员可以是无证、有证或有证的人员，他们为以下人员提供文件协助
physicians or other licensed healthcare providers.抄写员也可以协助电子病历导航，数据定位和检索，编码，
and other activities.

Research suggests that scribes might improve provider satisfaction, boost efficiency and productivity, and help providers interact more
directly with patients, fostering greater trust and patient engagement.3

However, 在医疗保健环境中使用抄写器需要仔细规划并考虑潜在风险. 下面的策略可以帮助医疗保健提供者和组织开发和实施使用抄写员的策略，以支持健全和全面的文档流程. 

1. 在组织文档策略中包括特定于抄写员的信息. Make sure policies adhere to state and federal laws, accrediting agency and third-party payer requirements, and professional guidance.
2. 为抄写员编写书面职位描述，详细说明所需的资格, experience, and training. 职位描述和雇佣合同也应该清楚地描述文员的职责, required competencies, and expectations for productivity.
3. 确保抄写员熟练使用组织的EHR系统，并具有访问系统的个人安全权限. 医疗保健提供者应建议抄写员如何应对患者就诊期间发生的EHR警报和通知.
4. 定期监督文员，以确保他们遵守其工作描述中定义的角色和职责，并且没有超出其认证或许可的范围进行实践.* 
5. Introduce scribes to patients during clinical encounters, 并解释他们在记录护理和促进更好的医患互动和沟通中的作用. 理解并遵守患者拒绝抄写员进入检查室的权利.
6. Review all scribe-generated documentation to ensure accuracy and completeness. 纠正任何不准确或不能完全代表所提供的护理的信息.
7. 在文件中包括一份声明，证明(a)主治临床医生提供了记录员记录的服务, (b)解释一名抄写员(包括抄写员的姓名)记录了提供护理的情况, 并且(c)确认临床医生审查了文件的准确性和完整性.
8. 提供签名和日期/时间，以确认审查和批准所有抄写员生成的文件. 确保抄写员在组织政策要求的所有文件上签字. (注:一些认证机构和第三方付款人要求抄写员签署文件.)
9. 确保审稿员生成的文件在组织文件政策规定的时间范围内进行评审和适当的签字.
10. Provide orientation and ongoing training for scribes; training should cover federal and state privacy regulations, organizational documentation policies/standards, patient rights, etc.
11. Routinely assess scribes’ competency and review their performance. 审核抄写员生成的文档是否符合组织文档和隐私/安全策略.
12. 为业绩改进提供建设性的反馈和可衡量的目标. 考虑在组织质量改进计划中包括与抄写功能相关的关键指标.
13. Monitor for changes in federal and state laws, accreditation and payer requirements, 以及与适当使用抄写员记录临床护理相关的专业指导.
14. 确保医疗保健提供者知道如何在没有抄写员的情况下独立导航和操作EHR系统.

Resources

• American College of Emergency Physicians: Scribe FAQ
• 美国健康信息管理协会:在医生实践中使用医疗抄写员
• Family Practice Management: What Can a Scribe Do for You?
• Medscape: How Should 'Scribes' Be Used? Scribes Rules, Explained
• The Joint Commission: Documentation Assistance Provided By Scribes

Endnotes

1  Ziemann, M., Erikson, C., & Krips, M. (2021). The use of medical scribes in primary care settings: A literature synthesis.
Medical Care, 59(Suppl 5), S449–S456. http://doi.org/10.1097/MLR.00...
2  Ibid.
3  Ibid; Gidwani, R., Nguyen, C., Kofoed, A., et al. (2017, September/October). Impact of scribes on physician satisfaction,
patient satisfaction, and charting efficiency: A randomized controlled trial. Annals of Family Medicine, 15(5), 427-433.
doi: 10.1370/afm.2122; Mishra, P., Kiang, J. C., & Grant, R. W. (2018). Association of medical scribes in primary care with
physician workflow and patient Experience. JAMA Internal Medicine,178(11), 1467–1472.
doi:10.1001/jamainternmed.2018.3956; Shultz, C. G., & Holmstrom, H. L. (2015). The use of medical scribes in health
care settings: A systematic review and future directions. Journal of the American Board of Family Medicine, 28(3),
371-381.

本文件不构成法律或医疗建议，不应被解释为规则或建立护理标准. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, 如果您对您的法律或医疗义务或权利有任何疑问，请联系您的律师或其他专业顾问, state or federal laws, contract interpretation, or other legal questions.

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