Documentation Tips

Documentation Tip: Scribes

Documentation Tips: Scribes

A Scribe is defined as an individual who is present during the physician’s performance of a clinical service and documents (on behalf of the physician) everything said during the course of the service.  Medicare describes a Scribe as one who follows the doctor around and writes word for word what the doctor says as he’s examining the patient – a sort of human tape recorder.

With the exception of obtaining PFSH and ROS, a scribe cannot act independently and may only document the practitioner’s conversation and/or activities and relay information and cues back to the physician during the visit.

When an NPP/Resident/Student acts as a scribe for the physician the medical record should clearly indicate the NPP/Resident/Student is acting as a scribe. Documentation is considered to be scribed when the NPP/Scribe/Student writes notes into the medical record while the physician is personally performing the service.

Although it happens less frequently, Scribes can and do transcribe services for NPPs.  In this case the same rules apply as when documenting for a physician.

Scribed documentation must clearly display the name of the scribe, the role of the individual documenting the service (i.e. scribe) and the provider of the service. The physician is ultimately responsible for all documentation and must verify that the scribed note accurately reflects the service provided.

Documentation of scribed services should indicate who performed the service and who recorded the service.

The scribe’s note should include:

  • The name, title, and signature of the scribe.
  • The name of the practitioner providing the service.

Sample Scribe attestation:

“Entered by __________________, acting as scribe for Dr./PA/NP ____________________.”  Signature________________ Date____________ Time___________

The practitioner’s note should indicate:

  • Affirmation the practitioner personally performed the services documented.
  • Confirmation he/she reviewed and confirmed the accuracy of the information in the medical record.
  • Acceptable practitioner signature.

Sample Practitioner attestation:

“The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me.”  Signature______________________ Date__________________ Time________________

A Scribe is defined as an individual who is present during the physician’s performance of a clinical service and documents (on behalf of the physician) everything said during the course of the service.  Medicare describes a Scribe as one who follows the doctor around and writes word for word what the doctor says as he’s examining the patient – a sort of human tape recorder.

With the exception of obtaining PFSH and ROS, a scribe cannot act independently and may only document the practitioner’s conversation and/or activities and relay information and cues back to the physician during the visit.

When an NPP/Resident/Student acts as a scribe for the physician the medical record should clearly indicate the NPP/Resident/Student is acting as a scribe. Documentation is considered to be scribed when the NPP/Scribe/Student writes notes into the medical record while the physician is personally performing the service.

Although it happens less frequently, Scribes can and do transcribe services for NPPs.  In this case the same rules apply as when documenting for a physician.

Scribed documentation must clearly display the name of the scribe, the role of the individual documenting the service (i.e. scribe) and the provider of the service. The physician is ultimately responsible for all documentation and must verify that the scribed note accurately reflects the service provided.

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