Scribes

Published
Title: Scribes
Standard #:

DC-324

 Issued: 12/09/2014 Reviewed/Revision Date:

DEFINITIONS

Scribe – A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or non-physician practitioner (NPP).  A scribe is present during the physician’s or NPP’s service and documents everything said during the course of the service.  An individual acting as a scribe must not be seeing the patient in a clinical capacity and must not interject their own observations or impressions.

A scribe is one who follows the doctor around and writes word for word, what the doctor says as he/she is examining the patient.  CMS compares this role to that of a human tape recorder.

This definition makes it clear that the physician is providing the service while the scribe is recording only information cited by that provider.

STANDARD

The purpose of this policy is to ensure the proper documentation of clinical services when the billing provider has elected to utilize the services of a scribe.

  1. All individuals to serve as a scribe must review the policy on the use of scribes and sign an agreement (refer to below Scribe Agreement) which states that the scribe will adhere to the policy.  The agreement must be signed prior to accepting the role of a scribe.  The department is responsible for maintaining a copy of the signed agreement and providing a copy to the Office of Culture, Ethics and Compliance, upon request.

PROCEDURE

When providers choose to utilize the services of a scribe, it is imperative to adhere to the procedure as outlined below.

Scribe Requirements:

  1. A scribe’s entry can be hand-written, dictated or created/typed in an electronic medical record (EMR). Individuals can only create a scribe note in an EMR if they have been assigned a role with scribing privileges and utilize their corresponding unique password.
  2. The scribe does not provide medical care to the patient during this encounter.
  3. The scribe is solely recording what is verbalized by the provider.
  4. The name of the scribe must be identified in the medical records. The scribe must sign and date the documentation.
    • Example: “I (Scribe Name) am acting as a scribe for Dr. xxx.”

 Provider Requirements:

  1. The provider must review the scribed medical record entries and edit, as appropriate.
  2. The provider must sign and date the documentation and include a statement of their authentication of the scribed medical record entries. When authenticating the scribed entries, the provider is confirming they have reviewed these entries for accuracy.
    • Example: “I have reviewed the scribed information for accuracy.”

REGULATORY REFERENCES

The Joint Commission, Standards FAQ, Use of Unlicensed Persons Acting as Scribes

http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=426&ProgramId=47

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.

 

Scribe Agreement

Scribe Agreement

I hereby certify that I have reviewed the Office of Culture, Ethics and Compliance Scribe Policy.  I understand that as a scribe I am:

Required to be present during the physician’s or non-physician practitioner’s performance of a clinical service and document (on behalf of the provider) everything said during the course of the service.  I am not seeing the patient in any clinical capacity and must not interject my own observations or impressions.

Documentation of my scribe service must include a personal, dated note that:

  • Identifies me as the scriber of the service
  • Attests that the notes are written/recorded contemporaneously in the presence of the physician or non-physician practitioner performing the service
  • Identifies the physician or non-physician practitioner
  • Date and Signature of the scribe
  • Date and Signature of the physician

Example of a compliant scribe statement – “I (scribe  name) am acting as a scribe for Dr. (physician’s name).”

I am aware that documenting in the EMR requires me to first have an assigned, unique password to the EMR.  Documenting under some else’s log in is prohibited.

(Please Print)

Name:________________________________________________________________________

Department:____________________________________________________________________

Signature:_____________________________________________________________________

Date:_________________________________________________________________________