Four Tips for Scribing During a Survey
on 3/21/2017 10:00:00 AM
There's a lot that happens during an accreditation survey; document reviews, staff interviews, visits to care areas, etc. Most hospitals have some type of plan for managing different aspects of the survey process - including the use of scribes. Scribes perform a vital role in the survey process. They are - in a sense - real-time historians, capturing what a surveyor says and does. Following these simple tips can help your hospital use scribes to your best advantage:
One Scribe - One Surveyor
Each surveyor should be assigned a scribe to be with him/her for the entire duration of the survey. Whenever possible, have the same individual assigned to the same surveyor. This will help both the scribe and the surveyor develop a consistent communication process.
Understand the Role of a Scribe
Ideally, the scribe should have no other duties during a survey activity. Their primary purpose is to record what the surveyor is saying, what the surveyor is looking at, who the surveyor interviews, and to funnel any requests a surveyor makes to your command center. I recommend that the scribe discuss his/her role with the surveyor so that there is no confusion or misunderstanding while the survey is occurring.
Scribes Need to Document
Information obtained by a scribe is critical. It will help you manage your survey effectively, as well as codify observations and data to use after the fact should your hospital wish to contest findings. Scribes should use a standard information collection form that garners at least the following:
- The patient name, medical record number, and admission/treatment date for any medical record reviewed by a surveyor
- The name and title of any staff person or physician interviewed by a surveyor. This information should be forwarded to either Human Resources or the Medical Staff Office in case the personnel or credential files of these individuals are pulled for review
- The name, medical record number, and admission/treatment date of any patient interviewed by a surveyor
- Any salient observations or statements made by the surveyor – especially if it appears that there is a deficient practice observed
Accuracy is Key
Scribes need to record information accurately. If a scribe is not clear on what a surveyor is saying or requesting, they should not hesitate to seek clarification from the surveyor. The more accurate the information, the better your hospital can act on it. If a surveyor makes a request for additional information, the scribe should:
- Verify exactly what the surveyor is requesting
- Confirm when the surveyor would like to receive the information
- Transmit the request as quickly as possible to your command center
Following these simple tips will assure your scribes are a positive force in your survey management plan.
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About the Author
Richard Curtis RN, MS, HACP
RN, MS, HACP
Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.