A. A scribe is a medical assistant who transcribes into the medical record what a physician dictates while an exam takes place. Scribes may not elaborate on or make extraneous notations into the medical record based on their own interpretations. In addition, a scribe assists the physician in locating tests or prior-visit information pertinent to the encounter.
There are many reasons why practices utilize scribes. In addition to efficiencies, scribes allow physicians to focus their attention on the patient while the exam takes place and ensure that documentation in the medical records does not suffer. For paper charts, a scribe may improve legibility. For both paper and electronic records, a scribe may improve the quality and quantity of the notes.
Q. Can scribes improve productivity?
A Yes. For a practice that has never utilized scribes, changes to processes and flow need to occur before the practice will see improved productivity. But, with the support of physicians, well-trained scribes integrated into a workflow that utilizes them to their full potential can increase a physician’s productivity.
Q . Are there restrictions on what a scribe can record in the medical record?
A. Organizations such as health-care systems, teaching facilities and hospitals generally have different requirements regarding the use of scribes. There may be differences between inpatient and outpatient settings. A scribe cannot document some services, such as extended ophthalmoscopy; only the physician can make accurate retinal drawings.
Q. Do Medicare Administrative Contractors provide any guidance or policies for the use of scribes?
A. Some do, so it is best to check with the relevant MAC. For example, First Coast Service Options, MAC for Florida, provides this answer to the frequently asked question on their website:
“Medicare policy is not opposed to the use of personnel as scribes. However, the medical record must include documentation that the physician reviewed and confirmed the information stated by the scribe.”
Novitas, the MAC for several states, says that while the physician must perform the service,
“ … the scribe may document what is dictated and performed in the medical record. Documentation of scribed services must clearly indicate:
• who performed the service;
• who recorded the service;
• the qualifications of each person (i.e., professional degree, medical title); and
• be signed and dated by both the physician … and scribe.”
Q. If the MAC does not provide any specific guidance, is it necessary for the physician to document that a scribe entered the data into the medical record?
A. Even when there is no specific instruction, the physician should attest to the accuracy of the scribe’s note. A physician might write, “I agree with the above documentation” or “I agree the above information is accurate and complete” to show that the notes in the medical record have been reviewed by the physician and are as intended. The absence of an attestation may cast doubt on the accuracy of the record. In electronic medical records, there should be a mechanism for the physician to indicate that the scribe’s entries were reviewed and verified.
Q. Are there other considerations for scribes when the practice utilizes EMR?
A. Yes. While EMR tracks, via log-in, who makes entries in the medical record, it does not make it clear if that person is a scribe, technician or physician. For this reason, best practices include requiring that:
• scribes log in to document information dictated by the physician;
• physicians log in to sign charts (do not allow scribes to sign charts for physicians); and
• physicians review, edit and correct the scribe’s notations and attest to the completeness and accuracy of the record.
Scribing is different from taking measurements such as visual acuity or intraocular pressure; the same person should not perform these functions concurrently. If the person can function as both a scribe and tech, consider two different log-in passwords to facilitate the distinction for reviewers.
Q. Do scribes require certification or other special training?
A. Not yet. According to Novitas’ Scribe Services Guidelines, published in their December 2011 Medicare Report, “a scribe can be a Non-Physician Practitioner (NPP), nurse or other ancillary personnel allowed by the physician to document his/her services in the patient’s medical record.” Novitas requires “…the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice … [and] any other relevant regulations.”
Scribes should have legible handwriting, familiarity with data entry and present a professional appearance. Although not responsible for code selection, scribes should have a working familiarity with ICD coding.
Q. For the purposes of achieving meaningful use with electronic health records, are there any limitations associated with the use of a scribe?
A. Yes. One of the meaningful use core measures is “Use computerized physician order entry (CPOE) for medication orders.” The Stage 1 CPOE rules state,
“Any licensed [emphasis added] healthcare professionals can enter orders into the medical record … for the objective of CPOE if they can enter the order per state, local and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that the CPOE occurs when the order first becomes part of the patient’s medical record and before any action can be taken on the order. Each provider will have to evaluate on a case-by-case basis whether a given situation is entered according to … [the above].”
The key word is “licensed;” as discussed, scribes are not licensed.
Q. Will the rules for Stage 2 meaningful use allow the scribe to use CPOE for medication orders?
A. The new final rule for Stage 2, published on September 4, 2012, altered who is authorized to enter CPOE orders:
“Any licensed healthcare professional or credentialed medical assistant, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant. The revision allowing MAs to enter CPOE orders is available for reporting years 2013 and beyond regardless of the Stage of Meaningful Use.”
Q. Are there specific types of certification that qualify the scribe to enter CPOE orders?
A. No. The Centers for Medicare & Medicaid Services did not specify a certifying body. CMS’ only requirement is that the source of the credential(s) be an organization different from the employer. Examples include a medical assistant degree or certification from an organization such as the American Association of Medical Assistants, the Joint Commission on Allied Health Personnel in Ophthalmology or the American College of Medical Scribe Specialists. This list is not exhaustive of certifying entities. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.