Guidance on Use of Scribes
Over the last few years, several Medicare Administrative Contractors (MACs) have published information regarding medical record documentation by someone other than the rendering provider. Recently, Cahaba GBA published a news item on documentation requirements when scribes are utilized. It can be found at: https://www.cahabagba.com/news/guidelines-for-the-use-of-scribes-in-medical-record-documentation-2/ We were particularly drawn to the following part.
Documentation of scribed services must include the following:
- Who performed the service;
- Physician co-signs the note indicating the note is an accurate record of both his/her words and actions during that visit
- Example: I, Dr. _____, personally performed the services described in this documentation, as scribed by ___________ in my presence, and it is both accurate and complete.
- Who recorded the service;
- Record entry notes the name of the person “acting as a scribe for Dr. X”
- Example: I, _________, am scribing for, and in the presence of, Dr. _______________.
- Qualifications of each person
- Signed and dated by both the physician and the scribe
The guidelines describe a more rigorous notation than other publications on this topic but it reinforces the need to document the use of the scribe in the medical record. Scribes should be instructed to document exactly what occurs during the exam and what is said by the physician to the patient during the patient encounter. There is no latitude for the scribe to include their own comments or ideas in the medical record. Best practices include the scribe’s name and signature on the visit note along with the date of service and patient name. It is also suggested by many other MACs that the physician’s note include the following information:
- Affirmation of the physician’s presence during the time the encounter was recorded
- Verification that the information was reviewed and is accurate
- Supplemental information if the note is lacking
While Cahaba is just one MAC, and not the standard bearer for all other MACs, we encourage you to review instructions from your local MAC as well as other third party payers about this issue.
Significantly, only the physician can sign the note authenticating its accuracy. Physicians should not give scribes their password to electronically sign the note nor should they allow the scribe to sign the note by hand for them. In 2010, the Centers for Medicare and Medicaid Services (CMS) provided detailed instructions on physician signature both written and electronic. (For more information on physician signature, see our FAQ on this topic.)