Student Dissertation

Agency : EHR, Medical Scribe; Medical Scribing Error; SOPs

Objective : The specific objectives of the study are: • To measure the percentage of medical scribing error. • To identify the causes leading to medical scribing errors.

Background : A Medical Scribe is essentially a personal assistant to the physician; performing documentation in the EHR, gathering information for the patient's visit, and partnering with the physician to deliver the pinnacle of efficient patient care. Prescribing faults and prescription errors are major problems among medication errors. They occur both in general practice and in hospital, and although they are rarely fatal they can affect patient’s safety and quality of healthcare. Medication errors are among the most common medical errors in hospitals. Scribing error is a specific type of medication errors and is due to data entry error that is commonly made by human operators. Prescription errors encompass those related to the act of writing a prescription, whereas prescribing faults encompass irrational prescribing, inappropriate prescribing, underprescribing, overprescribing, and ineffective prescribing, arising from erroneous medical judgment or decisions concerning treatment or treatment monitoring.

Methodology : Study Design Descriptive research design. Duration of study The study was carried out from a period of 5 Feb 2018 to 5 May 2018. Study area IKS Health, Mumbai Data collection method Sample Size: 450 medical chart notes (150 medical chart notes per month). 30 Medical Scribe. Data analysis procedure Data were analyzed using Microsoft Excel and graphical representation including Bar Graphs, Pie charts of the result done as per the need of the study.

Findings : In February 2018, minor errors comprise the major part of total errors with 66%. Major errors and feedback comprise 18% and 15% respectively. One percent of critical errors are present. In March 2018, minor errors comprise the major part of total errors with 71%. Major errors and feedback comprise 18% and 9% respectively. Two percent of critical errors are present. In April 2018, minor errors comprise the major part of total errors with 72%. Major errors and feedback comprise 19% and 7% respectively. Two percent of critical errors are present. There is a remarkable increase in the errors (critical errors, major errors and minor errors) from February (2018) to April (2018). Feedback decreases from 36 to 17 in the same duration. The biggest concern is an increase in the critical errors, from two to six.

Recommendations : There was a remarkable increased in the scribing errors seen in the given time duration (February 2018 to April 2018). A slight change in company policy in creating an employee-friendly working environment along with standardized training process may well reduce many of the errors. It is certainly not a panacea to address the problem, however, and systems to address and ameliorate new and continuing errors need to be sought and implemented.


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