Scribe FAQ

 

FAQ 1.  What is a scribe?

A scribe works side by side with the practitioner as a documentation and throughput assistant. The scribe can accompany the practitioner into the exam room and document the practitioner-patient encounter as it is verbalized by the practitioner and patient. The practitioner may also dictate the patient encounter to the scribe. Additionally, the Scribe can gather data for the physician including (but not limited to) nursing notes, prior records, lab and radiology results, facilitating the efficiency of the patient's visit. With the exception of obtaining PFSH and ROS, a scribe cannot act independently, but simply documents the practitioner's conversation and/or activities and relays information and cues back to the physician during the visit.  

 

FAQ 2.  What should be documented when using a scribe in the Emergency Department?  

 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 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 _________

    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 signatures. 

    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 _______

     

    FAQ 3.  Does CMS have any policies permitting or prohibiting the use of scribes?

    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).   
  • 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. 

     

     FAQ 4.  Have any Medicare carriers developed guidelines regarding the use of scribes?

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

     

Palmetto Jurisdiction 11  (pdf document)

Palmetto Railroad Medicare  (pdf document)

Novitas

http://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid;jsessionid=-GvryCUvju_XRl1Z7OYk9lIET7XEMNSpp_KDTb4fc20iMahNU5WM!1026769936!-1829413973?contentId=00003295&_afrLoop=766488978946460#!%40%40%3F_afrLoop%3D766488978946460%26contentId%3D00003295%26_adf.ctrl-state%3Dkpbe0u51s_4

WPS 

https://www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/reimbursement/WPS%20-%20Guidelines%20for%20the%20Use%20of%20Scribes%20in%20Medical%20Record%20Documentation.pdf

NGS 

https://www.acep.org/uploadedFiles/ACEP/practiceResources/issuesByCategory/reimbursement/NGS%20scribes.pdf

First Coast

    

CGS

www.cgsmedicare.com/partb/pubs/news/2012/0412/cope18560.html

Cahaba

 https://www.cahabagba.com/news/guidelines-for-the-use-of-scribes-in-medical-record-documentation-2/

Noridian

https://med.noridianmedicare.com/web/jfa/provider-types/nonphysician-practitioners/medical-scribe

FAQ 5.  Who can act as a scribe?

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 are 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.

 

FAQ 6.  Can Medical Students serve as scribes?

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.

 

FAQ 7:  Does The Joint Commission (TJC) have any policies permitting or prohibiting the use of scribes?

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 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."   Scribes also need to meet the same HIPAA and HITECH standards as other practitioners in the Emergency Department.

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.

 

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org.

Updated 01/29/2017

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