CMS, or Content Management System Guidelines, include a software application or other related programs that are used to create and manage any digital content. The Medicare Administrative Contractors and the Medicare Claims Processors have begun to enforce and strengthen documentation guidelines for medical scribes.
If a practice is currently using the EMR system, it is vital that the scribes are being updated and trained so that they meet all the requirements to continue to use the digital records system. A required template update has been put into place and requires that the following questions be answered:
- Who performed the service?
- Who recorded the service?
- What are the credentials or qualifications of the scribe?
All documentation is to be signed and dated by both the physician on duty, as well as the scribe that was present during the patient interaction. A scribe’s responsibilities and job description can vary from practice to practice. These differences could also mean that there can be slight variances within the CMS guidelines for that particular practice. It is the physician’s responsibility to define and communicate the job description, the policies clearly, and the guidelines and procedures to the scribe they have employed. They must also always be sure that all individual state laws and guidelines are being followed.
All aspects related to the entry of a patient’s personal health information should be documented according to the guidelines set forth. Everything should be done with the direction and in the presence of the physician. The information from the appointment is entered into the computer by the medical scribe in real time and is checked by the physician to ensure accuracy. The information is entered into the system, and the scribe has their own personal security credentials to access the EHR or EMR system.
All scribes must be knowledgeable and trained concerning information management, HIPAA, HITECH, confidentiality, and patient rights and standards. Some information that is entered into the system by the scribe includes:
- The patient's medical history
- Results and notes of the physical examination
- Vital signs
- Progress notes are given by the doctor
- The continued care plan set by the doctor
- Medication lists
Verification that the physician checked the information should be noted as well as any additional information, the date, and the time it was authenticated.
To find the right medical scribe that has the required knowledge, experience, education, and qualification to handle personal medical records then contact ProScribe MD today. We have scribes trained and knowledgeable in all these areas including the documentation and auditing protocols that should be followed.