Medical Scribes and Compliance

Medical scribes work alongside licensed practitioners as documentation and throughput assistants. The scribes accompany the practitioner into the exam room and document the practitioner-patient encounter as the practitioner and patient verbalize it. The practitioner may also dictate the patient encounter to the scribe after the encounter takes place.

Scribes are also used to gather such items as nursing notes, prior records, lab and radiology results, thus facilitating the efficiency of the patient’s throughput.  A scribe cannot act independently, but simply documents the practitioner’s conversation and/or activities and relays information into the medical record.

CMS does not offer any official guidance on the use of scribes.  CMS officials have responded to direct inquiries about the use of scribes.

  •  Medicare policy is not opposed to the use of personnel as scribes. Medicare does not pay separately for the use of a scribe.  The E/M service is a face-to-face encounter between the patient and the practitioner. The scribe functions as a recorder of facts and events, which occur between the practitioner and the patient during the encounter.  There must be evidence that the practitioner reviewed and confirmed what the scribe transcribes.
  • Pursuant to the Medicare Documentation Guidelines, the only information a scribe can independently document is the ROS and PFSH elements that can be recorded by ancillary staff or taken from a form completed by the patient.
  • CMS does not prohibit Non-Physician Providers (NPP’s) from using scribes.
  • Services of a scribe are not separately reimbursable.
  • A scribe does not need to be employed by the practitioner(e.g., hospital employee).
  • When a scribe enters on a paper medical record and correction is needed, the provider must add and sign an addendum to the scribe’s note, rather than cross out or alter what the scribe has written.

TJC Standards for Scribes

  • A job description that recognizes their unlicensed status and defines their qualifications and extent of responsibilities.
  • Training and Orientation specific to the organization and to their role.
  • Performance evaluations and competency assessments
  • Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights’ standards as do other hospital personnel.
  • If the provider employs the scribe all non-employee HR standards apply.  If the scribe is provided through a contract then the contract standards also apply.
  • Signing (including name and title), dating of all entries into the medical record-electronic or manual   For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff.
  • The provider must then authenticate the entry by signing, dating and timing it. The scribe cannot enter the date and time for the physician or practitioner.
  • Although allowed in other situations, a physician or practitioner signature stamp is not permitted for use in the authentication of “scribed” entries– the physician or practitioner must actually sign or authenticate through the clinical information system.
  • The authentication must take place before the physician or practitioner and scribe leave the patient care area since other practitioners may be using the documentation to inform their decisions regarding care, treatment and services.
  • Authentication cannot be delegated to another physician or practitioner. The organization implements a performance improvement process to ensure that the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being entered into the medical record by scribes.
  • Amongst other things, TJC surveyors will expect to see signing, timing, and dating of all entries into the medical record by the scribe, and authentication by the physician or licensed independent practitioner prior to them leaving the work area.  In the updated FAQ, TJC does not support scribes being used to enter orders for physicians or practitioners “due to the additional risk added to the process.”

Sample Scribe attestations: 

  • “Entered by______, acting as scribe for Dr/PA/NP ________” Signature________Date____ Time______
  • I personally scribed for Dr. ______ on 12/10/14 at 0736. Electronically signed by scribe_____ on date ___ at time ___

Sample Practitioner attestations: 

  • “The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me.” Signature______________________ Date_______________________Time________________
  • Portions of this note were transcribed by scribe ________.  I, Dr. ________ personally performed the history, physical exam and medical decision making; and confirmed the accuracy of the information in the transcribed note

Authenticated by Dr. ___ on ______ at _______

Additional resources can be found at the American College of Medical Scribe Specialists (theACMSS.org), jointcommission.org, and cms.gov.

Written by,

Tim Taylor, MD FACEP

Founder & Chief Medical Officer