Scribes Let Physicians Focus on the Patient
Know their role, benefits, and requirements for documenting encounters in the medical record.
With the adoption of electronic health records (EHRs), providers often find themselves paying more attention to the computer screen in the exam room—filling out the appropriate fields and checking all the necessary boxes — than to their patients. Certainly, more than just patient satisfaction suffers in such a scenario.
In the wake of quality care, some providers are taking measures to remedy the situation. Recognizing that caring for patients and documenting that care are really two separate jobs, many providers are reinstituting the age-old occupation of scribes.
Scribes Find New Purpose
Much of what we know about our past is due to the work of scribes, who diligently worked to record the life and times of our ancestors. More recently, scribes are becoming integral to the patient encounter, allowing physicians to return focus on their patients without sacrificing documentation. In fact, documentation improvement efforts can benefit from the employment of scribes.
Training to Be a Scribe
Medical scribes are expected to document what they see, hear, and observe between the provider and patient in the exam room. Although there are no mandatory national or state licensures or certifications required, the American College of Medical Scribe Specialists offers Certified Medical Scribe Specialist (CMSS) training and certification, which are obtainable online. The American Healthcare Documentation Professionals Group offers online training and administers the Medical Scribe Certification Exam, which entitles those who pass to hold the AHDPG certification.
Regulating the Use of Scribes
From a regulatory perspective, neither the Centers for Medicare & Medicaid Services (CMS) nor The Joint Commission require certification. Both groups weigh in on the use of scribes, however.
The Joint Commission doesn’t take a stand on whether scribes should be used in practice, but they have gone so far as to develop the following standards when using scribes to document patient encounters:
- A job description should be created that recognizes the unlicensed status of the scribe and clearly defines the scribe’s qualifications and extent of the responsibilities.
- The scribe should receive orientation and training specific to the organization and the role.
- The scribe must undergo competency assessment and performance evaluations.
- All employment and sub-contractor standards apply to scribes, as well.
- Scribes must meet all confidentiality and patient rights standards as do all other personnel.
- Scribes must sign (name and title) and date all entries into the medical record, clearly distinguishable from the physician’s entries.
- The physician or practitioner must then authenticate the entry by signing, dating, and timing it. The physician’s date and time cannot be entered by the scribe, nor can the authentication be done by another provider.
- A physician or practitioner stamp is not permitted for use in the authentication of scribed entries.
- The authentication must take place before the physician, the practitioner, and scribe leave the patient care area.
CMS communicates their position on scribes through Medicare administrative contractors (MACs), most of whom offer some guidance for how they expect scribes to be used in professional practice. Here are examples of various MAC positions.
National Government Services (NGS)
NGS indicates the scribe is present during the encounter and records in real time as the actions and words of the physician occur. Scribes may not interject their own observations or impressions into the medical record. Physicians may rely on the review of systems and past, family, and social history obtained by ancillary personnel. The scribe note should include the name of the scribe, the name of the physician providing the service, the name of the patient, the date of service, using language such as “acting as a scribe for Dr. ___.” The physician’s note must affirm their presence during the time the encounter was recorded, show verification the physician reviewed the scribed information and that it’s accurate, and any other information the provider deems appropriate. A legible provider signature is required.
Some organizations have policies in place to encourage both consistency and compliance surrounding scribe use. An affirmation statement such as this may be used: “I personally evaluated the patient and reviewed the history, physical examination, assessment, and plan as documented by [SCRIBE NAME and TITLE]. My significant findings and changes have been incorporated into the note as needed.”
CGS indicates that the scribe is functioning as a “living recorder,” documenting in real time the actions and words of the physician as they are done. If this is done in any other way, it’s inappropriate. The real-time transcription must be clearly documented by both the scribe and the physician.
Novitas provides additional information, indicating that a scribe can be a non-physician practitioner (NPP), nurse, or other ancillary personnel allowed by the physician to document their services in a patient record. The medical record should clearly indicate when an NPP is scribing (and not providing a clinical service).
CAHABA and WPS
According to CAHABA and WPS, the physician who receives the payment for the services must be the person delivering the services and creating the record, which is simply “scribed” by another person. Novitas also indicates the scribe does not have to be employed by the physician (i.e., contracted scribe services), and must scribe documents that are dictated and performed by the physician or NPP. The use of the scribe must also be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws, and other relevant regulations.
Unlike what is indicated in The Joint Commission standards, when a scribe is used by a provider to document medical record entries (e.g., progress notes), CMS does not require the scribe to sign/date the documentation. This was recently reported in Pub. 100-08 (Medicare Program Integrity) Transmittal 713, effective June 6, 2017:
Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.
Scribes Facilitate Quality Care
In a climate where patient satisfaction and improved health outcomes are tied to physician reimbursement, it has never been a better time to reinstitute the age-old profession of the scribe. Providers who can spend less time with technology and more time with patients will excel in quality payment initiatives.
The Joint Commission, Standards FAQ Details
Medicare Program Integrity CMS Manual System, Pub. 100-08, Transmittal 713, Change Request 10076: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R713PI.pdf
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