Use Scribes Appropriately
Ensure your practice follows guidelines when using scribes to populate EHRs.
By Jill Young, CPC, CEDC, CIMC
Scribes should be a medical record concern for healthcare practices. They offer meaningful benefits — especially for technologically challenged or time-strapped providers — but used inappropriately, scribes quickly become a compliance risk.
Know the Scribe’s Role
Electronic health records (EHRs) have brought to the forefront the use of scribes, whose basic task is to document in the patient record. Medical and nursing students are good candidates for the job because of their knowledge of anatomy and medical terminology. The reality is, however, that there are no training and certification requirements to become a scribe.
To better understand the rules and policies governing scribes, first define their role. The Joint Commission, which accredits and certifies healthcare organizations and programs, released the following guidelines in July 2012:
A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner. It is the Joint Commission’s stand that the scribe does not and may not act independently but can document the physician’s or practitioner’s dictation and/or activities.
Carrier guidelines consistently define the intent of a scribe as “one who documents what the physician communicates.” For example, when a family member of mine visited the emergency department last year, a scribe accompanied the physician during her examination. The scribe’s computer was worn like a mobile desk around her neck, and she typed as the physician talked. This was an appropriate use of a scribe.
Some policies go farther when describing the scribe’s role, as shown in these excerpts from various Medicare administrative contractors’ (MAC) policies:
Cahaba GBA: Documentation of the scribed services must include:
- Who performed the service
- Who recorded the service
- Qualifications of each person
- Signed and dated by both the physician and the scribe
The policy concludes, “It is important … that the ‘scribe’s’ services are used and documented appropriately, and that the documentation is present in the medical record to support that the physician actually performed the service at the level billed” [emphasis in original].
Source: Cahaba GBA
WPS Medicare: “Hospital or nursing facility E/M services documented by a Non-Physician Practitioner (NPP) for work that is independently performed by that NPP, with the physician later making rounds and reviewing and/or co-signing the notes, is not an example of a ‘scribe’ situation. … In the office setting, the physician’s staff member may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS), and may act as the physician’s ‘scribe,’ simply documenting the physician’s words and activities during the visit” [emphasis in the original].
Source: WPS Medicare
Palmetto GBA: “If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed and sign his/her name. The name of the scribe must be identified in the medical records.”
Source: Palmetto GBA, Frequently Asked Questions, “What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?”
Novitas: “While the physician or NPP must perform the medical service, the scribe may document what is dictated and performed in the medical record.” Novitas provides examples of how the provider and scribe should document their participation in the medical record.
CGS: “The scribe is functioning as a ‘living recorder,’ documenting in real time … This individual should not act independently, and there is no payment for this activity.”
Source: CGS Medicare
Scribes can be a cost effective, efficient addition to your practice. In addition to documenting the patient encounter in real time, scribes may also assist providers in navigating the EHR to locate information such as test results and lab results, according to The Joint Commission. Especially when transitioning to an EHR, providers may be grateful for the help.
What Scribes Can’t Do
In contrast to the above guidelines, scribes should not:
Independently document details of an encounter outside the exam room. The scribe may have been present in the room at the time of service, but he or she is not acting as a scribe if content is added to the patient record after the fact.
Populate templated exams before the provider’s interaction with the patient, which would result in documented exam details not performed.
Pulling forward or cutting and pasting documentation from a prior patient visit that is irrelevant or incorrect to the current encounter. The provider may review the information, but the scribe is not allowed to act independently, and pre-population is always inappropriate.
Wholly create procedure/surgery dictation. This is inappropriate. The provider must dictate the note, which the scribe records or documents, only. Any action falling outside the definition of “human transcriptionist” is not scribing.
Evidence of inappropriate use of scribes is everywhere. One telling example is “The Disturbing Confessions of a Medical Scribe,” in which an anonymous scribe tells of a provider asking him to document smoking cessation services that were not performed, among other abuses. A scribe may remind the provider if he or she has forgotten an element needed to meet Meaningful Use requirements, for instance, but the scribe should not document anything unless the physician performs the element and dictates that action to the scribe.
To ensure your practice is using scribes in a compliant manner, consult the MAC guidelines for your jurisdiction. Most policies include specific signature requirements, as outlined above. Policies also may prohibit an individual from performing any clinical duties while acting as a scribe — even if he or she is a qualified provider. Educate your staff on compliant use of scribes. Follow up by auditing chart documentation recorded by scribes and the process that resulted in those records.
Jill Young, CPC, CEDC, CIMC, has more than 30 years of medical experience working in all areas of the medical practice, including clinical, billing, and rounding with physicians. She has a unique style of teaching using real life examples of coding and billing situations, and humor at a fast pace to keep participants engaged and informed. Her expertise is used in several publications and heard on a variety of audio conferences. She speaks at educational lectures for the Michigan State Medical Society and other national organizations, including The Coding Institute and Eli Research. Young has been a workshop presenter nationally for AAPC, and a topic speaker at AAPC National Conference. She has held office for the Lansing, Mich., local chapter and has served on the AAPC Chapter Association board of directors.