A scribe works side by side with the practitioner as a documentation assistant. The scribe accompanies the practitioner into the exam room and documents the practitioner-patient encounter as it is verbalized by the practitioner and patient.  A scribe cannot act independently, but simply documents the practitioners dictation and/or activities during the visit.  

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________________

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 is transcribed by the scribe.
• ­A scribe is one who follows the practitioner around and writes word for word, what the practitioner says as he’s examining the patient – a sort of human tape recorder.
• 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).
  

Yes.  Below are documents from several different Medicare Carriers related to scribes:

Palmetto Jurisdiction 11

Palmetto Railroad Medicare

Novitas

WPS

NGS

Trailblazer

The scribe is only recording the words and descriptions of the service performed and verbalized by the practitioner. Since scribes have no patient care responsibilities, there are no training or background requirements regarding who can act as a scribe. 

Although there is no documented restrictions as to who can act as a scribe, payers have expressed concern about residents or NPPs acting as scribes because of their ability to independently evaluate the patient separate from the physician and the difficulty in separating documentation performed when acting as a scribe versus documentation of services performed as a healthcare provider.   

Medical students frequently act as scribes. The documentation should be clear that the medical student is functioning as a “living recorder”, documenting the words of the practitioner. 

The Joint Commission does not endorse nor prohibit the use of scribes.

The Joint Commission published an updated FAQ July 2012 concerning the standards that apply to the use of unlicensed persons acting as scribes.  TJC FAQ indicates that a scribe does not and may not act independently but can, at the direction of a physician or practitioner (Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant), document the previously determined physician’s or practitioner’s dictation and/or other activities. 

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.  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.”  

For a complete list of TJC requirements delineated in the standard see the reference below.

http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=426&StandardsFAQChapterId=66