Medical Scribes: A Compliance Checklist
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. A scribe’s core responsibility is to capture accurate and detailed documentation (handwritten or electronic) of the encounter, in a timely manner. 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 EHR.
It is crucial that scribe programs are included in the organization’s overall compliance program. You must closely monitor use of scribes for accuracy and adherence to applicable guidelines, through the development of policies and procedures, training, and overall management.
Scribe documentation must be managed and maintained with the same quality assurance and compliance expectations of other patient care documentation. Policies and procedures identify responsibilities and outline requirements for scribes, while also setting the tone and defining expectations and accountability.
Here’s a quick checklist for compliant use of medical scribes:
- Enact a policy to define a scribe’s role, to include a documented job description. Minimum guidelines include:
- Scribes may document only the words and activities as they are performed by the qualified provider during a patient encounter
- The policy clarifies CMS documentation signature requirements
- Definition of roles (e.g., scribe vs. provider)
- Responsibilities and clear scope of practice
- Certification and licensure requirements
- Define the scribe’s function as a living recorder, documenting in real time the actions and words of the qualified provider as they are completed.
- The individual writing the note or entry in the record should note, “Written by [Jane Doe], acting as scribe for Dr. [Smith].” Dr. [Smith] should co-sign, and indicate that the note accurately reflects work and decisions made by the provider.
- Stipulate 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 E/M service level because they do not reflect the work of the qualified provider.
- Train scribes on specific documentation requirements, to include:
- The name of the scribe on the office visit note, with a legible signature
- The name of the patient for whom the service is provided is clearly noted
- Authentication of the scriber
- The office visit note dictated must clearly indicate who performed the service
- The office visit note dictated must clearly indicate who recorded the service
- The date, and signature of the qualified provider and the scribe, must appear on the office visit note
- Train providers on specific documentation requirements, to include:
- An affirmation of the qualified provider’s presence during the time the encounter was recorded
- Verification that the qualified provider reviewed the information typed in the office note
- Verification of the accuracy of the information
- Authentication of the provider, including date and time
- In a teaching facility, attending physicians may employ scribes, but residents or fellows may not because the creation of the medical record is inherent to the training programs and medical care that residents deliver.
- Only those individuals with a personal password/access to the EHR may scribe a note.
- Documents scribed in the EHR must identify the scribe’s identity and authorship of the document, in both the document and the audit trail.
- Providers must personally give verbal orders; they cannot use a scribe to transmit orders.
- Signing (including name and title) and dating of all entries into the medical record is necessary, for both electronic and manual documentation.
- The provider must authenticate the entry by signing, dating, and timing (for deemed status purposes). The scribe cannot enter the date and time.
- All entries regarding a patient’s health information are completed in the presence of, and at the direction of, the provider.
- Third party payers may have specific guidelines for how a scribe documents, and how the electronic signature is applied. Identify and document third party specific requirements.
- Obtain a signed agreement between the provider and the scribe, delineating expectations and accountability.
- Assure that policies and scribe workflows adhere to each applicable specific MAC guidelines for the practices jurisdiction (e.g., Cahaba allows the scribe to document PFSH and ROS independent of the qualified provider, in the office setting for an E/M service).
- Monitor scribe notes routinely to ensure documentation is performed in accordance with organizational guidelines and requirements.
- Conduct an annual (at minimum) review to validate scribing documentation requirements are met. Audit results should be maintained and accessible, in accordance with organizational retention guidelines.