What is team documentation?
Team documentation, also referred to as “scribing,” is a process where staff assist with documenting visit notes, entering orders and referrals and queuing up prescriptions in real-time while in the exam room with the physician and the patient. This frees the physician to focus on the patient.
Why team documentation?
Electronic health records (EHRs) have altered the documentation process in physician practices. Tasks previously performed by staff (e.g., receptionists, medical transcriptionists, medical assistants, pharmacists and/or nurses) such as data gathering, organization and entry, have shifted to physicians.
What will the net savings of implementing team documentation be for my practice?
Enter the amount of time per day spent by physicians on documentation activities that could be eliminated by hiring a documentation specialist. The result will be the cost-benefit of implementing team documentation in your practices.
Calculate your savings
Cost of physician's time
Clinic days per year
Full-time documentation specialist
Documentation specialist hourly rate (including benefits)
Total time savings
Physician documentation time saved
Total financial savings
Gross annual savings with
Annual cost of dedicated
Net practice savings with
Source: AMA. Practice transformation series: team documentation.. 2014.
Eight steps to team documentation
- Create a change team
- Decide who will help with documentation
- Determine the model: Clerical Documentation Assistant (CDA) or Advanced Team-based Care
- Start with a pilot
- Select the pilot personnel based on commitment
- Define your workflow
- Start small
- Meet weekly
Create a change team
Select a high-level champion and a multi-disciplinary team, including representatives from administration, nurses, MAs, information technology, compliance and physicians. It is helpful if all agree on the goals, such as improved patient and provider satisfaction, better quality and improved productivity.
Decide who will help with team documentation
Will it be an MA, a nurse, a pre-med student, a former transcriptionist or a dedicated scribe? The type of assistant will determine their scope of work.
Determine the model: clerical documentation assistant (CDA) or advanced team‑based care
Clerical documentation assistant (CDA) model: The CDA accompanies the physician during each patient visit and assists only with recordkeeping. Separate staff (nurses, medical assistants (MAs) or other clinical staff) or the physicians are responsible for the clinical aspects of care, such as obtaining vital signs, performing medication reconciliation or providing patient education. Typically there is one CDA per physician. In addition, the practice employs MAs and nurses to perform the clinical support functions.
Example: Non-clinical staff in the geriatric practice at the University of California, Los Angeles, serve as Physician Partners (P2s). The P2s document aspects of the office visit, facilitate the flow of patients through the office and improve the efficiency of ordering and/or scheduling tests and medications. Under the direction of the physician, the P2s enter all aspects of the patient encounter into the electronic health record (EHR), including the patient history, physical exam findings that are verbalized by the physician, procedures and clinic charges. They also queue orders that were discussed to during the visit for the physician to sign. At the close of the visit when the physician leaves the room to see the next patient, the P2 stays behind to review the after-visit summary with the patient, conduct any needed care coordination with other support staff and provide patient education. If labs are required, the P2 may also escort the patient there to improve patient flow through the clinic. After the P2 concludes the visit with the patient, they complete the encounter in the EHR and send the documentation to the physician for review. With this approach, the physician ultimately saves time because s/he only needs to review and sign documentation and queued orders.
In this practice, there are three P2s to every two physicians. This 3:2 ratio minimizes interruptions in the workflow by allowing continuous rotation of P2s in the clinic.
Advanced team-based care model: A specially-trained nurse or MA accompanies each patient from the beginning to the end of their appointment to provide team care services, such as health coaching, care coordination and in-reach panel management. In addition, the nurse/MA assists with the clinical documentation while the physician conducts his/her portion of the patient visit. Typically there are two to three nurses/MAs per physician and they perform all of the clinical support functions in addition to assisting with the documentation.
Example: In Dr. Kevin Hopkins' family medicine practice at the Cleveland Clinic, trained nurses and/or medical assistants follow a three-step process. There are two MAs per physician.
Step 1 (Pre-visit): The physician and team design protocols and templates for specific patient complaints and chronic conditions common to their practice. The MA uses these tools to guide the initial history they record during rooming. During this step the MA also updates the past medical, social and family histories, reviews and sets up orders for any health maintenance items that are due and reviews the patient's medication list and refills. She then exits the room and huddles with the physician to share what she has learned.
Step 2 (Visit): The MA and physician enter the exam room together. The physician confirms and expands upon the preliminary history and examines the patient, which the MA records in real-time. The physician then makes a diagnosis and crafts a treatment plan with the patient and MA. The MA continues to record the assessment and treatment plan and queues any orders for the physician's signature. The patient asks any further questions he or she may have and then the physician moves on to the next patient.
Step 3 (Post-visit): The MA remains with the patient to reinforce the treatment plan, provides an updated medication list and visit summary, engages in motivational interviewing and provides self-management support. She will then assist with appointment and referral scheduling.
Learn more about the expanded nurse/MA role in expanded rooming and discharge protocols.
So the cost of the additional personnel will always be somewhat of an issue, but, get this - we are actually making a profit (!) the first three months, despite the increased cost.
Who should assist with documentation?
The team member who assists with medical documentation varies across practices and specialties. The model may include clinically trained staff (e.g., MAs, LPNs, RNs, physical trainers, ophthalmology technicians, PAs and NPs) who can conduct elements of the patient visit themselves. The degree of task-sharing varies according to state and local scope of practice regulations, which may include taking visit notes, submitting prescription requests and/or renewals, entering laboratory test orders, administering immunizations and providing patients with supplemental health coaching. Alternatively, the model may include non-clinically trained staff, for whom the term “clerical documentation assistant” (CDA) can be used rather than “scribe.”
Will I need more space in the exam room to implement this process?
The size of the exam room is important. There needs to be enough space for the patient, one or more caregivers or family members, the physician and the CDA, nurse or MA. However, most practices may find they do not need to alter the size or configuration of existing exam rooms.
Start with a pilot
Developing collaborative care is hard work. It is best to start small. We suggest a pilot of one or two physicians. As institutional knowledge grows and bugs are worked out, the process can be spread to more physicians. Many practices report a three- to six-month learning curve.
Does the extra person interfere with the physician-patient relationship?*
We find that the extra person actually improves the physician-patient relationship because the physician is able to provide his or her full attention to the patient and is not distracted by data entry.
How do you position assistants in the exam room so they aren't intrusive?*
In an advanced team-based care model, the assistant helps interact with the patient during the visit and does not need to “disappear.” In one practice, the nurse and physician position themselves according to the care needs. When the patient is seated at the desk, the physician is also at the desk, and the nurse stands at the counter. When the patient is on the exam table, the physician stands at his or her side at the counter, and the nurse is at the desk. There is subtle choreography and the providers switch places automatically now depending on how they need to interact with the patient. Positioning also depends on the available technology infrastructure and hardware. Some practices use tablets for better mobility, but this can certainly be done with laptops or desktop computers as well.
Select the pilot personnel based on commitment
The physician should be willing to invest in training the staff and learning a new model. Staff should be enthusiastic about assuming new responsibilities and being trailblazers within the organization. They should also be eager to help shape the new process.
What qualities or skills should I look for in an assistant in the team care model?*
The most important skills are being personable, putting the patient at ease, and eliciting the preliminary history. It is also important to have good keyboarding skills and EHR-navigating skills. A minimum typing competency and timed typing test may be a good idea. An understanding of billing requirements also helps individuals document accurately.
Does the assistant perform all of the medical recordkeeping duties or do physicians still play a role?
This varies according to specialty and physician preference. In some practices, the assistant records the majority of the patient's medical history, exam, diagnoses and plan of care as indicated by the physician. In others, the assistant records portions of the patient's medical history, exam and administrative data. The physician may document key elements of the patient's medical history and medical decisions. In each example, the physician reviews and signs off on the medical record before the patient's visit is closed.
Doesn't Meaningful Use Stage 2 (MU2) require that only the doctor enter the orders?
No. According to MU2, “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE [computerized provider order entry] if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.” For more information, please visit the Centers for Medicare & Medicaid Services website regarding MU2 requirements.
Define your workflow
Identify who will perform which responsibilities during each patient visit. Will template notes be used? How will the provider sign the team notes and orders?
Determine which devices the assistant and physician will use. Will you use one computer or two? Will the computer be a laptop or a desktop? Consider your EHR features and functionality. Some EHRs allow only one user in the record at a time. Others allow the record to be “passed” from one user to another without being closed. Choreograph the work, and expect that it will be refined with experience.
Spend more time interacting with patients and less time looking at the computer #STEPSforward
How do I train existing staff in my practice to implement the collaborative documentation process?
Some physician practices contract companies that train medical documentation specialists. Others train their own staff. While the second option is a considerable investment of time, staff will learn exactly what is needed as it pertains to the specific practice. In both examples, training is ongoing. For instance, early in the implementation phase, the change team can consider debriefing daily to discuss what went well and identify opportunities for improvement. They can meet weekly for 30 to 60 minutes to review and adjust the workflow of the documentation process. They may also provide educational opportunities to learn more about clinical issues, billing and coding.
For the first few days you might do team care for only half of your scheduled patients, or for all of your patients only a few days per week. Use the rolling start to refine the process and avoid change fatigue.
Do patients mind discussing private issues with the assistant in the room?*
We have found that if the physician explains that the assistant's role is to ensure accurate documentation and handling the computer so the physician can remain focused on the patient, most patients accept and welcome the additional medical professional helping with their visit. Many patients even see it as an opportunity to have another advocate for their health care. When introducing the team care process, it may be reassuring to let patients know that it is no problem if they want to be alone with their physician. In addition, if the physician or assistant senses that the patient is uncomfortable—such as during certain sensitive parts of the visit—the assistant may leave the room. Exam rooms may also be fitted with curtains or screens that can provide additional patient privacy.
Training is ongoing. The physician and team should meet at least weekly for 30 to 60 minutes to review and adjust the workflow. The meetings can also be used to continue the educational process about clinical issues, billing and coding.
Is using an assistant more likely to result in documentation errors than doing it yourself?*
Accuracy and completeness of the documentation depends on training and a close working relationship between the physician and the assistant. In some ways, the documentation is likely to be more accurate because the assistant is focused on documentation while the physician is focused on providing care. In addition, the documentation is done in real-time, so there are fewer chances for details to be misremembered or confused between different patients. Some teams adopt a hybrid approach where the assistant does most of the documentation, especially those elements that are most suited to structured text entries, while the physician types or dictates a few additional lines explaining the medical thinking and more complicated details of the care plan.
We set aside one hour every Friday morning to go over the week: what worked well, what didn't and what changes we need to make. We edit our note templates during those meetings as well. We do some education, for example, why we do microalbumin testing on diabetic patients and other important clinical items. Learning why we do certain things gains buy-in. The new model has not only been good for patients and the physician, it has also been good for the MAs. The MAs are more fully engaged in patient care than they have ever been and they enjoy their work. They have increased knowledge about medical care in general and about their individual patients in particular.
Both the clerical documentation assistant (CDA) model and the advanced team‑based care model benefit the practice as a whole. Team documentation instills a sense of cooperation between staff at all levels of your practice, empowering them to take an active role in managing patient visits. Through ongoing training and weekly meetings, team documentation processes can evolve with your practice.
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- Ammann Howard K, Helé K, Salibi N, Wilcox S, Cohen M. Adapting EHR scribe model to community health centers: the experience of Shasta Community Health Center's pilot. Berkley, CA: Blueshield of California Foundation; 2012. http://www.blueshieldcafoundation.org/publications/adapting-ehr-scribe-model-community-health-centers-experience-shasta-community-health-c. Accessed April 2, 2014.
- Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008;15(7):35-40. http://www.aafp.org/fpm/2008/0700/p35.html. Accessed April 2, 2014.
- Anderson P. What is team care medicine? [video]. Yorktown, VA: Team Care Medicine, LLC; August 20, 2013. http://www.youtube.com/watch?v=1dPNn2OUuaA. Accessed April 2, 2014.
- Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490-494.
- Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. ClinicoEcon Outcomes Res. 2013;5:399-406.
- Center for Excellence in Primary Care. Health Coaching website. http://cepc.ucsf.edu/health-coaching. Accessed April 2, 2014.
- Hafner K. A busy doctor's right hand, ever ready to type. The New York Times. January 12, 2014. http://www.nytimes.com/2014/01/14/health/a-busy-doctors-right-hand-ever-ready-to-type.html?ref=katiehafner&_r=0. Accessed April 2, 2014
- Koshy S, Feustel PJ, Hong M, Kogan BA. Scribes in an ambulatory urology practice: patient and physician satisfaction. J Urol.. 2010;184(1):258-262.
- Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190-1193.
- Sinsky CA, Sinsky TA. In search of Joy in practice: innovations from 23 high-performing primary care practices [video]. Washington, DC: Patient-Centered Primary Care Collaborative; June 28, 2013. http://www.youtube.com/watch?v=tKVl74Al_I0. Accessed April 2, 2014.
- Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278. http://www.annfammed.org/content/11/3/272.full. Accessed April 2, 2014.
- Sinsky CA, Sinsky TA. Care by design. Redstone Clinic Case Study. 2011.
- Sinsky CA. Office of the future. Quincy Family Practice Case Study. 2011.
- Sinsky TA. Improving access, quality and satisfaction with “turbo practice.” Cleveland Clinic Case Study.
- Sinsky TA. Reconnecting with patients through scribing. Allina Clinics Case Study. 2011.
- Sinsky TA. The family team care model. Newport News Family Practice Case Study. 2011.
- Team Care Medicine v1 [video]. California: Sutter North Medical Foundation; November 4, 2013. http://www.youtube.com/watch?v=oBxHCkxnpgk. Accessed April 2, 2014.
- Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21(6):23-29.
- Chen Y, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016. 10.1007/s11606-016-3719-x
- Funk K and Davis M. Enhancing the role of the nurse in primary care: the RN "co-visit" model. J Gen Intern Med. 2015;30(12):1871-1873.
- Misra-Hebert AD, Amah L, Rabovsky A, et al. Medical scribes: how do their notes stack up? J Fam Pract. 2016;65(3):155-159.
STEPS in practice
How's it working in Vancouver, WA?
Physicians at The Vancouver Clinic (TVC) in Vancouver, WA, noticed that they were struggling to keep up with their increasing charting burden. In an effort to help the providers spend more time with patients and less time with charts, the practice decided to give scribes a try.
After testing different team documentation models, the clinic formed an agreement with a local scribing company. The company uses recent college graduates who are pursuing careers in medicine as physicians, nurses or physician assistants. This model worked well and is still in place. TVC has been impressed by the scientific training and vocabulary of these scribes and have found that they require little additional training.
The clinic studied different models to pay for the scribes. Physicians who used a scribe added one contact hour to their seven contact hour work day which covered the additional cost of the scribe. The clinic also found that adding a scribe and the corresponding clinic hour per day for 7 physicians creates the equivalent of one more physician FTE and extends the care that The Vancouver Clinic doctors can provide. Physicians are eligible to hire a scribe after practicing at the clinic for at least six months (to learn the EHR) and have to be busy enough to fill their added contact hours to offset the cost of the scribe. Even with the added contact hour the reduced charting burden saves them time each day. Data showed that one contact hour was added but two charting hours were removed, so the net was still a shorter day.
The scribes are welcomed by most patients. The purpose of the scribe was explained to patients during initial visits. The scribes wear scrubs and name tags like other members of the team. Patients have the option to decline the scribe, but this rarely occurs. An initial patient survey revealed that half of patients thought their visit was substantially better with the scribe in the room, and the other half felt neutrally about the scribe. On occasion the survey showed that the patient would have preferred a private conversation with the physician but was afraid to speak up. It is now at the discretion of the physician to ask the patient if they’d prefer to discuss without the scribe present if they sense the patient may be uncomfortable; they also may ask the scribe to leave if they believe this is what the patient will prefer.
Scribing is used successfully by a wide range of specialties, including primary care providers, urologists, ENTs, rheumatologists and orthopedic surgeons at The Vancouver Clinic. Approximately 60 physicians now use scribes and the number keeps growing. Working with scribes has increased physician satisfaction with their work. With the added support they are able to take on last minute patients without feeling burned out and overwhelmed by a heavy charting workload. They’ve commented, “I feel like I have my life back” and “I feel like I’m a real doctor again.” The improved physician experiences is a selling point for recruiting new providers to TVC.
How's it working in Strongsville, OH?
Kevin Hopkins, MD, family physician at the Cleveland Clinic, recalls overhearing triage nurses just outside his office tell patient after patient, “I'm sorry, we can't see you today, you'll have to go to Urgent Care.” As a family physician trained in the importance of the ongoing doctor‑patient relationship, Hopkins strove for continuity in his practice, yet he was spending so much of his day documenting care that many of his patients were being turned away.
Dr. Hopkins joined the Cleveland Clinic after finishing his residency in 2005. “My training program didn't have an EHR, so after my first two weeks here I wanted to dump the computers. It was so frustrating.” Even later, when the EHR “became my friend” and was indispensable, Dr. Hopkins felt he was putting his focus in the wrong place. “I was staring at the computer screen rather than looking at the patient. I was spending more time on documentation than on the patients.” He wasn't the only one to notice. “This is one of the biggest complaints we get from patients.”
“One day I realized if I didn't have to do this documentation I would really like my work.” Slowly he resolved to make changes. He and one of his MAs visited another physician who was using a team care model in his practice. Returning home, Dr. Hopkins and his colleague used this physician's model as a guide to develop templates specific to their practice and patients. Dr. Hopkins taught his staff how to use the health maintenance reminders in the practice's EHR to place orders for mammography screening, labs and immunizations. Workspace modifications were made, such as installing curtains to offer privacy to patients while the MA remains in the examining room and a computer workstation in the hallway to allow Dr. Hopkins to do minor note editing between patients.
“One of the challenges for me was letting go of some of the control, especially control over the computer. We also had to figure out ways for the MA to pull up information that I wanted on the screen when I wanted it. We have worked with the MAs to develop their multi-tasking skills. They need to be typing, listening to me, and watching what parts of the exam I am doing all at the same time. We trained them with shadowing and repetition.”
Dr. Hopkins and his team are continually refining their processes. “We set aside one hour every Friday morning to go over the week: what worked well, what didn't and what changes we need to make. We edit our note templates during those meetings as well. We do some education, for example, why we do microalbumin testing on diabetic patients and other important clinical items. Learning why we do certain things gains buy-in. The new model has not only been good for patients and the physician, it has also been good for the MAs. The MAs are more fully engaged in patient care than they have ever been and they enjoy their work. They have increased knowledge about medical care in general and about their individual patients in particular.”
How's it working in Auburn, IN?
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Team documentation implementation checklist
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Team documentation metrics
Measure the impact of the team documentation process.
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EHR Documentation FAQ
Federal rules governing entry of patient information into an electronic health record.
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