Obtaining a signed agreement between the provider and the scribe, delineating expectations and accountability.Identify and document third party specific requirements. Third party payers may have specific guidelines for how a scribe documents, and how the electronic signature is applied.All entries regarding a patient’s health information are completed in the presence of, and at the direction of, the provider.The scribe cannot enter the date and time. The provider must authenticate the entry by signing, dating, and timing (for deemed status purposes).
Verification of the accuracy of the information.Verification that the qualified provider reviewed the information typed in the office note.An affirmation of the qualified provider’s presence during the time the encounter was recorded.Training providers on specific documentation requirements, to include:.The date, and signature of the qualified provider and the scribe, must appear on the office visit note.The office visit note dictated must clearly indicate who recorded the service.The office visit note dictated must clearly indicate who performed the service.The name of the patient for whom the service is provided is clearly noted.The name of the scribe on the office visit note, with a legible signature.Train scribes on specific documentation requirements, to include:.Stipulating that if the qualified provider does not review and address the components of the office visit (i.e., the only documentation relating to the components is the entry from the nurse or a medical technician), these components may not be used in determining the Evaluation and Management service level because they do not reflect the work of the qualified provider.Defining the scribe’s function as a living recorder, documenting in real time the actions and words of the qualified provider as they are completed.Certification and licensure requirements.Responsibilities and clear scope of practice.The policy clarifies CMS documentation signature requirements.Scribes may document only the words and activities as they are performed by the qualified provider during a patient encounter.Enacting a policy to define a scribe’s role, to include a documented job description.Policies and procedures identify responsibilities and outline requirements for scribes, while also setting the tone and defining expectations and accountability.Ī quick checklist for compliant use of medical scribes: Scribe documentation must be managed and maintained with the same quality assurance and compliance expectations of other patient care documentation. One must closely monitor use of scribes for accuracy and adherence to applicable guidelines, through the development of policies and procedures, training, and overall management. It is crucial that scribe programs are included in the organization’s overall compliance program. Scribes are not permitted to make independent decisions or translations, beyond what is directed by the provider, while capturing or entering information into the health record or Electronic Health Record.Ī 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. A medical scribe is an unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner. Scribes aren’t licensed coders, but they should receive training in clinical terminology, basic CPT codes, EHR and of course HIPAA guidelines.Ī scribe’s core responsibility is to capture accurate and detailed documentation (handwritten or electronic) of the encounter, in a timely manner.