Glossary
Medical scribe
A medical scribe is a person, or more recently an AI tool, that records what happens in a clinical visit and writes it into the chart so the clinician can focus on the patient. The clinician remains responsible for the note and must check and sign it.
Updated October 17, 20264 cited facts, each traced to its source
Also called clinical scribe.
A medical scribe writes down the clinical encounter for the clinician. The name covers two kinds of work. One is a person who follows the visit and enters the notes. The other is an AI tool that listens to the visit and drafts the note. Both leave the clinician responsible for what the record says.
A human scribe documents, and the physician signs
Medicare's contractor guidance says that, in evaluation and management services, a scribe does not act independently. The scribe documents the physician's dictation and activities during the visit 1. That limit is what keeps the physician accountable for the record.
CMS's FAQ on electronic documentation says the 21st Century Cures Act lets a physician delegate electronic medical record documentation to a person performing a scribe function, provided the physician has signed and verified the documentation 2. The signature is the step that makes the note the physician's.
Ambient AI scribes are a newer kind
An ambient AI scribe listens to the visit and writes a draft note without a person in the room typing. A randomized trial at UCLA assigned 238 outpatient physicians across 14 specialties to two AI scribes or to usual care 3. The drafts still need checking. In a study of clinical notes generated by large language models, the hallucination rate was 1.47 percent, measured against clinician-annotated sentences 4. A hallucination is content the note states that the visit did not contain, so the reviewer has to look for it.
Ambient scribes are not the same as dictation. In dictation, the writer speaks to the software on purpose. In an ambient scribe, the software listens to a conversation the writer is having. Our overview of AI medical scribes covers the difference in more detail.
A concrete example
A cardiologist sees 20 patients in a morning clinic. A human scribe in the room enters the history and the physician's findings into the record during each visit. The physician reads each note and signs it before leaving the clinic. An ambient tool would do the same from the audio, and the physician would edit its draft instead.
Why it matters for dictation and typing
Scribes move the typing away from the clinician, but they do not remove the reading and signing. Whichever tool is used, the step that matters most is the clinician's check. A dictated draft and an AI draft both need that check, and both can carry errors into the chart if it is skipped.
The scribe also changes the time pressure. Finished notes that wait until the evening are part of pajama time, the after-hours work that many clinicians want to reduce.
Related terms
- Electronic health record is the system the scribe writes into.
- SOAP note is the note structure most scribes and dictated notes follow.
- AI dictation covers software that turns speech into text under the writer's control.
Guides that cover it
Evidence
Every number on this page, with where it comes from. Open a fact to see the exact words in its source.
- 1.Medicare's WPS guideline says that in evaluation and management services, a scribe does not act independently and simply documents the physician's dictation and activities during the visit.
WPS Medicare Part B, WPS Medicare Part B (Medicare Administrative Contractor), hosted by the American College of Emergency Physicians, 2009 · Original
- 2.CMS's FAQ says the 21st Century Cures Act lets a physician delegate electronic medical record documentation to a person performing a scribe function, provided the physician has signed and verified the documentation.
Centers for Medicare & Medicaid Services, Centers for Medicare & Medicaid Services, n.d. · Original
- 3.
- 4.
Related terms
- Dictation for Work: Doctors, Lawyers, Writers, StudentsThe topic this term belongs to
- Back-end speech recognitionBack-end speech recognition is a workflow in which the dictated audio is recognized and then edited by someone else, usually a transcriptionist, before it is signed. Its main trade-off is the cost and time of the second pass against the writer's own editing effort.
- CopytakerA copytaker was a typist in a newspaper office who took down stories that reporters dictated over the telephone. The Collins English Dictionary defines the role this way, and it predates the computer-based filing that replaced it.
- Dictation templateA dictation template is a block of text saved under a short spoken phrase, so one phrase inserts the whole block. Dragon calls these auto-texts, and Microsoft's Dragon Medical One guide documents the command that creates one from selected text.
- Electronic health record (EHR)An electronic health record (EHR) is a digital record of a patient's health information, built up over time from visits across care settings. The federal eCQI glossary also calls it an electronic medical record (EMR), and it is where dictated and typed notes end up.
- Front-end speech recognitionFront-end speech recognition is a workflow in which the person who dictates also reviews, corrects and signs the text, instead of passing the audio to someone else. The term is most common in radiology, where it is set against back-end transcription.
- Pajama timePajama time is the record-keeping that clinicians finish after their clinic day ends, often at home in the evening. A 2017 study of primary care clinicians measured 86 minutes of EHR work per weekday after clinic hours.
- Registered Healthcare Documentation Specialist (RHDS)The Registered Healthcare Documentation Specialist (RHDS) is a voluntary credential from AHDI for people who create healthcare documentation. It is awarded after an exam of 120 questions, and it is a prerequisite for the CHDS.
- ScopistA scopist edits the transcripts of official proceedings that court reporters create. Scopists are typically paid by the page, starting from $1.00 to $1.50 per page, and the role is also called transcript editor.
- SOAP noteA SOAP note is a structured clinical note with four parts: Subjective, Objective, Assessment and Plan. The format was developed by Larry Weed, and a StatPearls reference article describes it as a widely used documentation method for clinicians.
- Transcription line rateA transcription line is a unit of 65 characters, and the line count is the number of such units in a document. The transcription line rate is the price paid for each line, so the unit controls how transcribed work is measured.
Pages that use this term
- Dictation for Work: Doctors, Lawyers, Writers, StudentsTopic
- AI Medical Scribes and Ambient Clinical DocumentationGuide
- Medical Transcription: The Job, the Pay and AIGuide
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- Can you get a medical transcription job with no experience?Question
- Do patients have to consent to AI scribes?Question
- Does eClinicalWorks have built-in dictation?Question
- Should doctors use an AI scribe or dictation?Question
- What dictation software do NHS GPs and UK clinics use?Question
- What is an ambient AI scribe?Question
- What is medical transcription?Question
- What is the best medical dictation software for Windows?Question
- What is the difference between a medical scribe and a medical transcriptionist?Question
- What typing speed do you need to be a medical scribe?Question
- Dictation templateGlossary
- Electronic health record (EHR)Glossary
- Pajama timeGlossary
- Registered Healthcare Documentation Specialist (RHDS)Glossary
- SOAP noteGlossary