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
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:
by_____________________, acting as scribe for
· 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
- 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______________________
· 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
Palmetto Jurisdiction 11
Palmetto Railroad Medicare
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
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
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
;, 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
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.
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 firstname.lastname@example.org.