Who Is Writing Your Medical Record?

Posted on Tuesday, April 1st, 2014 at 1:00 am    

As more young (and not-so-young) lawyers are computer-literate, the trend in law firms is to decrease the number of secretaries and other support staff, as many lawyers do their own typing.  Yet in medicine, there is apparently a movement the other way, towards hiring “scribes” who accompany doctors while they see patients and type their notes for them.

A recent article in the Boston Herald reported that Brigham & Women’s Hospital is using the scribes in its Foxboro Urgent Care Center.  According to the Herald, a scribe “follows a doctor into a patient visit and takes real-time electronic notes while the doctor and patient talk. A scribe can be particularly helpful in hectic clinics, where health care providers have to move quickly to see lots of patients.”

So, let me get this straight.  In a hectic situation, where important health care decisions are being made, someone other than the doctor is deciding what to write in the medical records.  And going forward, the patient’s health may depend on whether the scribe has chosen the appropriate information to record, and has accurately recorded what was said.

From a patient safety perspective, the scribe system would seem to raise plenty of concerns.  The article is silent about many of the important details and safeguards:  What kind of education and training do the scribes have?  How do they decide what to write down?  Do the doctors proof read the records for completeness and accuracy?  And do they do that while the encounter is still fresh in their minds?  How and when do they correct errors?

It’s one thing if, as the Herald article mentions, resident doctors in training serve as the notetakers for their supervising physicians.  At least in that case, the “scribe” has been through four years of college (with significant scientific training), four years of medical school, and some post-graduate education.  They’ve had courses like anatomy and physical diagnosis.  Even then, there are many errors and inconsistencies in medical records, but I think most patients would have a lot more confidence in the record-keeping ability of a resident than a “scribe.”

While it’s certainly understandable that doctors love having personal secretaries, it’s really hard to imagine than this system can serve the interests of the patient.  Like young lawyers who type their own pleadings and correspondence, most young doctors are pretty adept with computer note-taking.  ANd most people find that the act of writing something down helps them to listen and remember what they’ve heard.  Since accurate records are essential to good patient care, it doesn’t seem like too much to ask to have doctors responsible for that accuracy.

And when something goes wrong–as it inevitably will–who will be responsible?  Will the patient ever know that a “scribe” prepared his record?  Will the scribe’s name be on the record itself?  Will doctors blame scribes for their mistakes?  Health care is complicated enough without interposing yet another barrier between patient and physician.